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PB89-916304 






For Reference 

Do Not Take 

From the Library 




For Reference 

Do Not Take 

From the Library 






NATIONAL 

TRANSPORTATION 

SAFETY 

BOARD 




"^7^^^ 



WASHINGTON, D.D. 20594 



RAILROAD ACCIDENT REPORT 



HEAD-ON COLLISION BETWEEN 

IOWA INTERSTATE RAILROAD EXTRA 470 WEST 

AND EXTRA 406 EAST WITH RELEASE OF 

HAZARDOUS MATERIALS 

NEAR ALTOONA, IOWA 

JULY 30, 1988 



NTSB/RAR 89/04 



UNITED STATES GOVERNMENT 



O^a/U TT I/O a/ 



TECHNICAL REPORT DOCUMENTATION PAGE 






1. Report No. 

NTSB/RAR-89/04 



2. Government Accession No. 

PB89-916304 



4. Title and Subtitle Railroad Accident Report-Head-on 
Collision Between Iowa Interstate Railroad Extra 470 West 
and Extra 406 East with Release of Hazardous Materials near 
Altoona, Iowa, on July 30, 1988 



3. Recipient's Catalog No. 



5. Report Date 
Julys, 1989 



6. Performing Organization 
Code 



7. Author(s) 



8. Performing Organization 
Report No. 



9. Performing Organization Name and Address 



(/. 



10. Work Unit No. 
4934B 



National Transportation Safety Board 
Bureau of Accident Investigation 
Washington, D.C. 20594 



11. Contract or Grant No. 



12. Sponsoring Agency Name and Address 

NATIONAL TRANSPORTATION SAFETY BOARD 
Washington, D.C. 20594 



13. Type of Report and 
Period Covered 

Railroad Accident Report 
July 30, 1988 



14. Sponsoring Agency Code 



15. Supplementary Notes 



16. Abstract: About 11:40 a.m. central daylight saving time on July 30, 1988, Iowa Interstate 
Railroad Ltd. (lAIS) freight trains Extra 470 West and Extra 406 East collided head on within the 
yard limits of Altoona, Iowa, about 10 miles east of Des Moines, Iowa. All 5 locomotive units from 
both trains; 11 cars of Extra 406 East; and 3 cars, including two tank cars containing denatured 
alcohol, of Extra 470 West derailed. The denatured alcohol, which was released through the 
pressure relief valves and the manway domes of the two derailed tank cars, was ignited by the fire 
resulting from the collision of the locomotives. Both crewmembers of Extra 470 West were fatally 
injured; the two crewmembers of Extra 406 East were only slightly injured. The estimated damage 
(including lading) as a result of this accident exceeded $1 million. 

The major safety issues in the accident include operational methods employed by the lAIS, 
training and selection of train and engine personnel, supervisory oversight by the lAIS, design of 
closure fittings on hazardous materials rail tanks, and oversight of regional railroads by the Federal 
Railroad Administration. 



17. Keywords: 

regional railroad;nonsignaled territory; yard limits; train 
orders; tank cars; hazardous materials; pressure relief 
valve; manway dome; head-on collision; fire; evacuation; 
FRA oversight; management oversight 



18. Distribution Statement 

This document is available to 
the public through the National 
Technical Information Service, 
Springfield, Virginia 22161 



19. Security Classification 
(of this report) 
UNCLASSIFIED 



20. Security Classification 
(of this page) 
UNCLASSIFIED 



21. No. of Pages 

101 



22. Price 



NTSB Form 1765.2 (Rev. 5/88) 



CONTENTS 



EXECUTIVE SUMMARY v 

INVESTIGATION 

Events Preceding the Accident 1 

Extra 406 East 1 

Extra 470 West 5 

The Accident 5 

Emergency Response 10 

Salvage of the Tank Cars 11 

Injuries 13 

Damages 13 

Extra 406 East 13 

Extra 470 West 13 

Track and Signal Information 15 

Track 15 

Signals 16 

Train Information 18 

Extra 406 East 18 

Extra 470 West 18 

Method of Operation 21 

Personnel Information 25 

Extra 406 East 25 

Extra 470 West 25 

Other lAIS Personnel 27 

Training of Operating Employees 27 

Operating Rules Classes 27 

Training Program for Engineers 28 

Operating Rules of the CNW 29 

Management Oversight 29 

Federal Activity 30 

Federal Oversight 30 

Accident Reporting Criteria and Previous Accidents 32 

Meteorological Information 34 

Medical and Toxicological Information 34 

Survival Aspects 34 

Transportation of Hazardous Materials 35 

Tank Car Design Standards 35 

Product Shipping Information 35 

Tank Car Securement Procedures at the ADM Cedar Rapids Plant 36 

Tests and Research 39 

Sight Distance Tests 39 

A-1 Charging Cut-Off Pilot Valve 39 

Air Brake Tests 39 

Postaccident Inspection and Pressure Tests of Tank Cars 40 

Manway Gaskets 41 

Other Information 41 

Disaster Preparedness 41 

Shelf Couplers 41 

Tank Car Fittings 42 

Railroad Event Recorders 42 

The American Short Line Railroad Association 43 



ANALYSIS 

General 44 

The Accident 44 

Operation of Extra 406 East 44 

Operation of Extra 470 West 47 

lAIS Method of Operation and Management Oversight 48 

Failure to Resolve Status of Signal System 48 

Failure to Verify Train Orders Issued 49 

Failure to Maintain a Record of Train Movements 50 

Failure to Install Yard Limit Signs 50 

Failure to Provide Instructions on Air Brake Tests 51 

Failure to Provide Adequate Training on the Operating Rules 51 

Failure to Provide Effective Training for Engineer Trainees 52 

Failure to Qualify Crews on Operating Rules of Other Railroads 53 

Failure to Conduct Operational Tests and Inspections 54 

Failure to Properly Abandon Signal System 54 

Lack of Cooperation by lAIS in Safety Board's Investigation 55 

Federal Activity 55 

Federal Oversight of lAIS 55 

Accident Reporting Criteria 57 

Transportation of Hazardous Materials 58 

Release and Ignition of Denatured Alcohol 58 

Mode of Release 59 

Tank Car Performance during Postaccident Testing 60 

Tank Car Securement Procedures and Training at ADM's Cedar Rapids Plant ... 61 
Federal Regulations Regarding Performance and Design of Closure Fittings 

on Hazardous Materials Rail Tanks 62 

Positioning of Tank Cars Within a Train 63 

Emergency Response 64 

Survival Aspects/Crashworthiness 64 

Event Recorders 65 

Toxicological Testing 65 

CONCLUSIONS 

Findings 66 

Probable Cause 69 

RECOMMENDATIONS 69 

APPENDIXES 

Appendix A--lnvestigation and Hearing 75 

Appendix B-Personnel Information 76 

Appendix C--lowa Interstate Railroad Timetable No. 2 (Excerpts) 77 

Appendix D--Chicago Rock Island and Pacific Railroad Company Rules and 

Instructions for Train Handling and Operation of the Air Brakes (Excerpts) 83 

Appendix E--49 CFR Part 217 (Excerpts) 87 

Appendix F--Safety Board Letter Dated December 7, 1988, and 

FRA Letter Dated January 18, 1989 89 

Appendix G~National Transportation Safety Board Accident 

Reporting Criteria 93 

Appendix H~Federal Railroad Administration Accident 

Reporting Criteria 95 

Appendix l--Bench Test Results of Pressure Relief Valves 98 



EXECUTIVE SUMMARY 

About 11:44 a.m. central daylight savings time on July 30, 1988, Iowa 
Interstate Railroad Ltd. (lAIS) freight trains Extra 470 West and Extra 406 East 
collided head on within the yard limits of Altoona, Iowa, about 10 miles east of Des 
Moines, Iowa. All 5 locomotive units from both trains; 1 1 cars of Extra 406 East; and 
3 cars, including 2 tank cars containing denatured alcohol, of Extra 470 West 
derailed. The denatured alcohol, which was released through the pressure relief 
valves and the manway domes of the two derailed tank cars, was ignited by the fire 
resulting from the collision of the locomotives. Both crewmembers of Extra 470 
West were fatally injured; the two crewmembers of Extra 406 East were only 
slightly injured. The estimated damage (including lading) as a result of this accident 
exceeded $1 million. 

The major safety issuesin the accident include: 

o operational methods employed by the lAIS; 
o training and Selection of train and engine personnel;; 
o supervisory oversight by the lAIS; 

o design of closure fittings on hazardous materials rail tanks; and 
o oversight of regional railroads by the Federal Railroad Administration 
(FRA). 

The National Transportation Safety Board determines that the probable cause 
of this accident was the failure of the traincrew of Extra 406 East to comply with the 
wait provisions of train order 213 and Iowa Interstate Railroad's (lAIS) inadequate 
oversight and enforcement of its operating rules. Contributing to the traincrew's 
failure to comply with the wait provisions was a combination of fatigue induced by 
irregular work/rest schedules, preoccupation with completing their assignment 
prior to exceeding duty time limits, inexperience, "mental set" or expectations 
based on previously issued train orders, the work activities which intervened since 
they received the train order, and the lAIS's inadequate training of its crews. 
Contributing to the accident was the Federal Railroad Administration's inadequate 
surveillance and enforcement of compliance by the lAIS with Federal regulations. 
Contributing to the length of the emergency was the release and burning of 
hazardous materials from pressure relief valves and manways on the tank cars. 

As a result of its investigation, the Safety Board issued recommendations to 
the Iowa Interstate Railroad, the Federal Railroad Administration, the Research and 
Special Programs Administration, the Archer Daniels Midland Company, the 
Chemical Manufacturers Association, the National Industrial Transportation 
League, the American Short Line Railroad Association, the Association of American 
Railroads, the Chicago North Western Transportation Company, the CSX 
Transportation Company, and METRA. The Safety Board also reiterated Safety 
Recommendation R-87-17 to the Research and Special Programs Administration. 



NATIONAL TRANSPORTATION SAFETY BOARD 
WASHINGTON, D.C. 20594 

RAILROAD ACCIDENT REPORT 

HEAD-ON COLLISION BETWEEN 

IOWA INTERSTATE RAILROAD EXTRA 470 WEST AND EXTRA 406 EAST 

WITH RELEASE OF HAZARDOUS MATERIALS 

NEAR ALTOONA, IOWA 

JULY 30, 1988 

INVESTIGATION 

Events Preceding the Accident 

Extra 406 East . --About 1:30 a.m., central daylight savings time on July 
30, 1988, the traincrew, which consisted of an engineer and conductor, of 
Iowa Interstate Railroad (lAIS) Extra 406 East reported for duty at their 
away-from-home terminal in Council Bluffs, Iowa, for a return trip to 
Newton, Iowa. (See figure 1.) The traincrew had gone off duty at Council 
Bluffs the preceding day at 5:30 p.m. and had been off duty for 8 hours, in 
accordance with the Hours of Service Act, when they reported for duty. 

The conductor stated that when they arrived at the yard office, he 
called the dispatcher who instructed them to add a fourth locomotive unit in 
anticipation of the tonnage that would be picked up en route to Newton. 
After coupling the locomotive units to their train, which had been made up by 
a switchcrew, and receiving an air pressure reading from the end-of-train 
device,^ the crew departed Council Bluffs about 2:35 a.m. with 32 cars. 

Extra 406 East proceeded to Atlantic, Iowa, a distance of 48.1 miles, 
where the crew picked up 25 more cars. After the crew recoupled their 
locomotive units to the train, the crew discovered a mechanically defective 
car which they then set out. Extra 406 East departed Atlantic about 
5:30 a.m. and proceeded to Winear, Iowa, a distance of 54.4 miles, where the 
crew picked up an additional 14 cars. At the next stop, Desoto, Iowa, a 
distance of 5.7 miles, the crew set out eight cars and picked up six empty 
cars. 

According to a copy of the dispatcher's train order book for July 30, 
1988, Extra 406 East received and acknowledged via radio train order 205 at 
3:37 a.m., when it was near Atlantic, Iowa. Train order 205 read: "Extra 430 
West meet Extra 406 East at Booneville, Extra 430 take siding." Westbound 
train Extra 430 West received and acknowledged the order at 6:08 a.m. 



^lAIS Extra 406 East was a cabooseless train equipped with an end-of- 
train (EOT) device that provided a red marker light at the end of the train. 
Additionally, by radio telemetry, the EOT provides the engineer a digital 
readout of the train line air pressure at the end of the train, and of any 
changes in air pressure. 



BLUE ISLAND 



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CEDAR RAPIDS 




MP 353.2 
MP 364.5 
BOONEVILLE 
DESOTO 
WINEAR 



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DES MOINES 



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At 8:37 a.m., the crew of Extra 430 West received and acknowledged via 
radio train order 209, which instructed them that train order 205 was 
annulled and that they could operate from Altoona to milepost (MP) 353.2, and 
await the arrival of Extra 406 East at MP 364. 5. ^ At 9:16 a.m., when Extra 
406 East was near DeSoto, the crew received and acknowledged via radio train 
order 211 which instructed the crew that train order 205 was annulled and 
that after Extra 430 West arrived at MP 353.2, Extra 406 East could operate 
from MP 353.2 to Newton. (In accordance with timetable instructions, the 
crews of Extra 406 East and Extra 430 West upon arriving at the mileposts 
designated in their respective train orders would contact the CNW yardmaster 
for instructions as to which track to take into and to leave the yard.) At 
9:18 a.m., shortly after leaving DeSoto, Extra 406 East received and 
acknowledged via radio train order 212, which instructed crews of eastbound 
trains between MP 353.2 and Newton, except Extra 406 East, to wait at MP 
353.2 until 2 p.m. 

At 9:39 a.m., while in the vicinity of Booneville, Iowa, Extra 406 East 
received train order 213, which stated: "Extra 406 East has right over' Extra 
470 West MP 353.2 to Newton and wait at Altoona [MP 346.9] until 1201 [12:01 
p.m.] for Extra 470 West." The conductor said he copied and repeated the 
order to the dispatcher. The conductor stated that he did not discuss the 
train order with the engineer or provide him with a copy. The engineer 
stated, however, that he clearly heard the transmission and the conductor 
repeat the train order. 

Extra 406 East proceeded through the yard limits at Des Moines, Iowa, 
over trackage of the CNW, en route to Altoona, a distance of approximately 
6.2 miles from the east end of the yard limits at Des Moines. In testimony 
after the accident, the engineer of Extra 406 East stated that "we met this 
[westbound] train down the DMU connection [CNW yard]. They were in the clear 
there for us." The engineer further stated that he did not remember the 
engine number of that train. The conductor of Extra 406 East stated 
following the accident that, "as we left the CNW we both compared our times. 
We figured. . .we've got about 2 hours and 35 minutes to get to Newton. We 
were always trying to make it in within our hours." When asked if he was 
concerned about this, he stated, "yes." 

The crew estimated that they arrived at Altoona shortly before 
11:30 a.m. Extra 406 East consisted of 4 locomotive units and 68 cars when 
it arrived at Altoona. The crew, after uncoupling the locomotive with one 
car and leaving the remainder of the train on the main track, proceeded 
through Altoona yard on the Pella Line track to set out the car on the 
"sawdust" track. (See figure 2.) After the crew set out the car the 



^ lAIS operates over trackage of the Chicago North Western (CNW) and the 
Des Moines Union (DMU) through the Des Moines area. MP 353.2 and MP 364.5 
are, respectively, the east and west end of the CNW yard limits at Des Moines. 

' The "right over" in the train order establishes the superiority of 
movement of a designated train (Extra 406 East) over another designated train 
(Extra 470 West). 



MP 346.0 



MP 346.1 
(POINT OF IMPACT) 



MP 346.6 



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conductor, who was off the train to line the switches, stopped to talk 
briefly with an lAIS communications worker. When he finished his 
conversation, the traincrew returned to the portion of the train that had 
been left on the main track, coupled the locomotive to the train, and 
departed eastward past Altoona Station prior to the time stated in train 
order 213. The engineer stated that he did not look at his watch before 
departing. The conductor stated that he thought he wrote down 11:30 - 11:40 
[a.m.] as the time of departure. 

Extra 470 West . --The engineer and conductor of Extra 470 West reported 
for duty at 8 a.m. on July 30, 1988, to operate the westbound train between 
Newton, approximately 25 miles east of Altoona, to Des Moines and return. 
The crew picked up the train consist list in the yard office and proceeded to 
a siding east of Newton to make up their train from a consist of 49 cars 
that earlier had been left in the siding. When Extra 470 West was ready to 
depart Newton, it consisted of one locomotive unit and eight cars, including 
two placarded tank cars. According to lAIS officials, the conductor of Extra 
470 West was responsible for the proper placement of cars in the train. The 
tank cars were the third and fourth cars behind the locomotive when Extra 
470 West departed Newton. 

The dispatcher's train order book for July 30, 1988, indicates that 
train orders for Extra 470 West were received in Newton by the assistant 
superintendent of operations who was performing the duties of train order 
operator on that date, as he occassionally did. He testified that he copied 
the orders, placed them on a desk for the traincrew to pick up, and saw a 
crewmember pick up the orders shortly after 10:30 a.m. Among the orders 
placed on the desk, according to the assistant superintendent of operations, 
were train orders 213 and 215, the second of which authorized Extra 470 West 
to run from Newton to MP 353.2, the east end of the CNW yard limits at Des 
Moines, and to return to Newton. 

According to the assistant superintendent of operations, the conductor 
of Extra 470 West did not report the time his train departed Newton and no 
one observed or reported the departure of Extra 470 West to the dispatcher. 
lAIS officials stated that it was at the option of the conductor to report 
the departure time of his train. 

En route to Altoona, Extra 470 West made only one stop at Colfax, where 
the second car behind the locomotive was set out in a siding at that 
location. The placarded tank cars, each of which were loaded with 
approximately 29,100 gallons of denatured ethyl alcohol, then became the 
second and third cars behind the locomotive. 

The Accident 

Departing Altoona, Extra 406 East traveled eastward and began 
descending on a 0.85 percent grade. The engineer stated that he made a 
"first service" reduction (5-7 pounds) of brakepipe pressure, using the 
automatic brake valve, which applied the brakes while moving down the hill, 
and that he then moved the throttle to the fifth position. While the train 
was moving in a left hand (direction of movement) 1 degree curve, the 



engineer observed Extra 470 West approaching. He estimated the two trains 
were about 300 feet apart and that his train was traveling between 15 and 
20 mph at the time. He stated that "I thought I put the train in emergency. 

I shut the throttle down, put the train in emergency " He stated that he 

left the engine through the cab door on the left (north) side of the cab of 
the engine, crossing over in front of the conductor who was sitting on that 
side of the cab doing paper work. He stated that as he was leaving the cab, 
he yelled at the conductor, "There's a train. Let's jump." The conductor 
stated that he did not hear the engineer say anything to him and that when he 
saw Extra 470 West coming around the curve, he positioned himself on the cab 
floor, braced his feet, and wrapped his arms around the control stand. A few 
seconds later, Extra 406 East and Extra 470 West collided head on within yard 
limit territory near MP 346.1. (See figure 3.) 

All four locomotive units of Extra 406 East derailed but remained 
upright and in line with the track. The lead unit of Extra 406 East 
overrode the locomotive unit of Extra 470 West. (See figure 4.) Eleven cars 
of Extra 406 East also derailed with the lead car overriding and striking the 
trailing locomotive unit. 

The first three cars of Extra 470 West, including the two placarded tank 
cars, derailed and overturned. (See figure 5.) Both tank cars overturned 
into a shallow ditch on the north side of the tracks with the top of each car 
facing north. Both tank cars were positioned about 90 degrees from the 
vertical. The lead car of Extra 470 West overrode the locomotive unit of 
that train. 

A log from the Polk County Sheriff's department indicates that three 
calls were received between 11:44 a.m. and 11:49 a.m. notifying the 
sheriff's department of the accident. A nearby resident, who stated that he 
heard the accident and saw a couple of cars "flip over," estimated that the 
accident occurred about 11:44 a.m. He notified the sheriff's department, 
and then he and his wife, an emergency medical technician, went to the 
accident scene where they arrived about 11:50 a.m. About the same time, an 
Iowa state trooper and a lieutenant from the Altoona police department, both 
of whom had been notified of the accident through the sheriff's department, 
arrived at the railroad grade crossing at NE 54th Avenue east of the 
accident. They left their vehicles and ran west down the railroad tracks to 
the accident site. When the state trooper reached the accident site, he 
encountered the engineer of Extra 406 East whom he described as "real upset." 

The trooper stated that the engineer informed them that he was unable to 
locate other crewmembers. In an effort to locate survivors, the lieutenant, 
the trooper, and the engineer climbed onto a "flat platform," which was what 
remained of the westbound locomotive. (According to the officers, they were 
not aware that this was the platform of the locomotive unit. Extra 470 West, 
until the engineer informed them.) The officers then climbed onto one of 
the derailed tank cars, ADMX 29477. At this point, the officers observed the 
body of one crewmember under one of the tank cars. The lieutenant stated 
that he noticed "... some leakage from a spout on the one tanker," on which 







Figure 3. --Extra 406 East (left) and Extra 470 West (right), 





Figure 4. --Unit 406 Overriding Unit of 470 West. 



the two officers were standing. They then copied the number from the 
placard on the side of the car and radioed the information to Polk County 
officials. The officers stated that they also observed a fire in the 
vicinity of the locomotive of Extra 470 West. According to the officers, the 
fire had not reached the two tank cars at the time. Because they believed 
that an explosion was possible, they left the immediate area. The officers, 
along with the emergency medical technician, the engineer, and the 
communications worker, who had heard the accident from her location at 
Altoona station and walked to the accident site, proceeded east toward the 
railroad grade crossing at NE 54th Avenue. 




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The engineer was helped by the emergency medical technician into an 
ambulance that had arrived at the grade crossing. The conductor, who had 
extricated himself from the cab and immediately left the wreckage area, was 
already in the ambulance. 

The communications worker later testified that the engineer stated, 

"Yeah it is [my fault] Why do you think I feel so bad? We had orders to 

wait at Altoona until noon, but we finished our work early, so we left at 
ten till." When questioned later about train order #213, both the engineer 
and conductor of Extra 406 East stated that the train order did not authorize 
them to leave Altoona before 12:01 p.m., that they did not wonder about the 
whereabouts of Extra 470 West, and that they could offer no explanation as to 
why they departed Altoona before the designated time. 

Emergency Response 

After receiving a call from the Polk County Dispatch, personnel from the 
Altoona fire department were dispatched to the railroad grade crossing at NE 
54th Avenue. The state trooper and the police lieutenant warned the fire 
department personnel who had just arrived at the grade crossing that product 
was leaking from one of the tank cars. The firefighters then proceeded down 
the tracks toward the wreckage. The firefighters observed at this time that 
the fire had now impinged upon the locomotive of the westbound train. The 
two fire units that had responded to the call were then directed to a 
location in a bean field about 1/8 to 1/4 mile southwest of the accident 
site, a location that the fire chief decided would be more accessible to 
fight the fire. 

From the number reported on the placard, the Altoona fire department was 
able to identify the product in the tank cars from the 1987 Department of 
Transportation's Emergency Response Guidebook. About 1:30 p.m., the fire 
department had one of the two trucks approach the accident site from the bean 
field and extinguish a grass fire on the south embankment about 40 yards 
west of the lead locomotive of Extra 406 East. One firefighter climbed on 
top of a derailed car from Extra 406 East and observed a flame at the west 
end of the west tank car, ADMX 29477. He stated that he realized it was 
product burning from the tank car because of the "flame's color and erratic 
movement." The firefighters then left the area of the tank cars because of 
the potential for an explosion of the tank car. 

At 12:53 p.m., the Polk County dispatcher notified the Des Moines fire 
department and requested assistance from the department's hazardous materials 
team. The five-man team arrived at the command post at 1st Avenue and 
Adventureland (NE 54th Avenue)^ about 1:08 p.m. Shortly afterward, two 
members of the hazardous materials team, wearing protective clothing and 
self-contained breathing apparatus, proceeded to the grade crossing at NE 
54th Avenue and approached the accident site along the tracks. They were 
unable to observe the west tank car, ADMX 29477, because trees obstructed 



Adventureland is the name of the street within the city limits of 
Altoona and the street becomes NE 54th Avenue in the county. 



11 

their view. However, they did observe the east tank car, ADMX 29494. One of 
the two team members stated that ADMX 29494 was on fire at one of the two 
pressure relief valves located on the top of the car. Although the second 
team member did not identify the specific location, he stated that product 
was venting and burning from ADMX 29494. He also noted that flame was 
impinging on the top of the tank car which was lying on its side. The 
hazardous materials team then withdrew from the accident site and returned to 
the command post. About 2:30 p.m, two members of the hazardous materials 
team, the superintendent of operations of the lAIS, a second lAIS employee, 
and the Altoona police chief approached the accident site from the south and 
west end of the tracks. The police chief and the two hazardous materials 
teammembers crossed to the north embankment and approached within 30 yards of 
the two tank cars. The two hazardous materials team members reported that 
they observed that both tank cars were burning from the pressure relief 
valves and that flames were impinging upon both tanks. 

Shortly after the second approach, representatives from the lAIS, the 
Iowa State Patrol, the Polk County sheriff's office, and the Altoona police 
and fire departments met and agreed to permit the tank cars to burn and 
initiate an evacuation of those residents living within a 1 1/2-mile radius 
of the burning tank cars. An approximate 3/4-mile radius evacuation was 
eventually established to allow for traffic flow around the area. The 1987 
Emergency Response Guidebook recommends to "isolate for 1/2 mile in all 
directions if the tank car... is involved in fire." The evacuation area was 
bordered on the east by 88th Street SE and 80th Street, on the west by First 
Avenue North, on the north by NE 62nd Avenue, and on the south by US Route 6. 
(See figure 6.) An estimated 1,500 citizens were evacuated. ^ 

A field inspector for the Association of American Railroads (AAR) 
arrived in Altoona about 9:20 p.m. on July 30, at the request of the lAIS to 
provide technical assistance. Upon arrival, he proceeded to the accident 
site to inspect the tank cars and noted that both cars were burning "from the 
dome areas and out of the safety valves." 

During the period from late evening on July 30 to the early morning 
hours of August 1, the tank cars were left to burn. Police department 
personnel continued to man control points around the area and kept the area 
clear of sightseers. During this time, the railroad made arrangements with a 
contractor, Hulcher Services, Inc., to clear the wreckage. On July 31, the 
contractor began positioning equipment needed to clear the wreckage. 

Salvage of the Tank Cars 

Hulcher began clearing the wreckage about 7 a.m., on August 1, from 
the west end of the wreckage and worked east toward the tank cars. 



•" The Altoona police chief estimated 75 percent compliance with the 
evacuation on Saturday, July 30, and 50 percent compliance on July 31. The 
evacuation was lifted at 6:00 p.m. on Monday, August 1. 



12 




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ALTOONA BOUNDARY 



DC 



USRT6 
(8TH ST. SE) 



4 00 

1987 
MAP OF ALTOONA, IOWA 

SOURCE: ALTONNA POLICE DEPT. 



Figure 6. --Evacuation Area of Altoona. 



13 

Before Hulcher personnel reached the tank cars, a Safety Board 
investigator and representatives from the lAIS and the Archer Daniels Midland 
Company (ADM), the owner of the tank cars, approached the accident site 
about 9:00 a.m. to observe the tank cars. The fire at ADMX 29477 had 
extinguished itself during the night of July 31 and the morning of August 1. 
The group observed that tank car ADMX 29494 was burning around the manway 
cover (see figure 7) and that liquid was leaking from the manway opening in a 
steady drip. Liquid was observed leaking from the center of the pressure 
relief valve on the "A" end or leading end of ADMX 29494, but was not 
burning. Moments before the tank cars were to be righted, ADMX 29494 was 
sprayed with alcohol foam to extinguish the fire burning around the manway 
cover. 

Once the tank cars were upright, lAIS decided to mount the tank cars on 
trucks and move them just west of the crossing at NE 54th Avenue where the 
remaining alcohol in each car could be off loaded. West Side Salvage, the 
company contracted to off load the alcohol, estimated that approximately 
21,000 to 23,000 gallons were recovered from ADMX 29494 and 13,000 to 15,000 
gallons from ADMX 29477. 



Injuries 



Injuries Extra 406 East Extra 470 West Total 

Fatal 2 2 

Serious GO 

Minor 2 2 

None _0_ 

Total 2 2 4 



Damages 



Extra 406 East . --The lead unit of Extra 406 East received major crush 
damage to the front with sheet metal displacement that extended 2.5 feet to 
the rear. The interior of the cab of this unit was destroyed by the post- 
accident fire. The remaining units received light to moderate damage. The 
trailing unit received damage when it was struck and overridden by the first 
car of the consist. Three of the 11 cars that derailed were destroyed. 

Extra 470 West . --The only locomotive unit in the consist of Extra 470 
West was completely destroyed by impact. 

The postaccident visual inspection of the two tank cars on the afternoon 
of August 2 revealed a dent in the tank shell head at the B-end, or leading 
end, of ADMX 29477, the lead tank car (second car from the head end) in the 
train. When facing the B-end, there was a crease on the left side of the 
tank shell just forward of the first circumferential weld seam in the side 
shell. The tank shell was scorched and burned around the manway and the 
pressure relief valve toward the A-end. The scorched and burned area 
extended about 2/3 the tank length from the manway toward the A-end and on 
the side of the tank that faced up on the overturned tank. The paint around 
the manway had been burned away, or was blistered. There was no visible 



14 




Figure 7. --Burning at Manway Cover of ADMX 29477 (foreground) and ADMX 29494. 



warpage, buckling, or other obvious indications of structural damage to the 
tank shell observed. The bottom outlet valve extension and cap did not have 
any obvious damage. The manway cover and nozzle were not visibly warped. 
The area where the gasket contacted the manway cover had some unknown residue 
that had burned, but had no visible scars or marks. 

The A-end of ADMX 29494, which had been the leading end of the car, had 
no visible damage. A small crease was found in the tank shell on the side 
that had been on the ground toward the B-end of the tank car. The tank 
shell was scorched around the manway opening and the pressure relief valve 
toward the A-end of the car. The scorched area extended around the side of 
the overturned tank that faced up, but it did not extend toward either end of 



15 

the tank. The paint in areas adjacent to the scorching was blistered. The 
bottom outlet valve extension and cap showed no visible damage. The manway 
nozzle and lid were not visibly warped or deformed. 

The initial damage estimate by lAIS (based on depreciated value) was: 

Equipment $562,000 
Track (600 feet) 60,000 
Wreckage/Clearance 60,000 

Total damages including lading were expected to exceed $1 million. 
Although the Safety Board requested the lAIS to provide its final estimate of 
damages, this information has not been provided. 

Track and Signal Information 

Track . --The accident occurred on the single mainline track within yard 
limits about .8 mile east of Altoona, Iowa, near MP 346.1. The Altoona 
station is located at MP 346.9^, and is listed in lAIS Timetable No. 2, dated 
April 15, 1987. The lAIS established the Altoona yard limits by general 
order No. 2, dated January 1, 1988, from MP 346.0 to MP 347.5. By general 
order No. 22, dated July 8, 1988, the railroad designated the roadway signs 
that were to be installed.^ On the day of the accident, no roadway signs had 
been installed. 

The track was constructed of 119-pound RE continuous welded rail (CWR). 
The rails were laid on tie plates with two rail holding spikes per plate on 
7-inch by 9-inch by 8-foot 6-inch treated timber crossties at about 21-inch 
centers. The CWR east and west of the derailment site was box anchored every 
fourth tie. The track within the accident location was on a 1 degree curve 
to the left (based on the direction of movement of Extra 406 East) and had 1 
1/2-inch superelevation. The length of the curve is about 1,429 feet. There 
was heavy foliage on both sides of the track in this area. The track profile 
at the point of collision (MP 346.1) was level with a 0.85 percent ascending 
grade for westward trains and a 0.76 percent ascending grade for eastward 
trains. About 600 feet of track were destroyed in the derailment. 

According to lAIS Timetable No. 2, the authorized maximum timetable 
speed for subdivision 3 was 40 mph. (In 1986, the track had been 
rehabilitated to meet the minimum standards for a Federal Railroad 
Administration (FRA) designation of class 3 track. The maximum operating 
speeds for FRA class 3 track are 40 mph for freight trains and 60 mph for 
passenger trains.) However, the engineering officer stated that because of 
high temperatures, train order 610 had been issued on July 11, 1988, 



Altoona station is designated by a sign on a small metal building 
near the Main Street grade crossing. 

The roadway signs to be installed included a "Yard Limit Approach" 
sign to indicate that the yard limits were located 1 mile in advance of the 
yard limits, and a "Yard Limit" sign to indicate the yard limits. 



16 

instructing trains not to exceed 25 mph between MP 325.0 and MP 350.8; this 
order had been in effect 24 hours per day since that date. Extra 470 West 
and Extra 406 East had both been issued train order 610 on the day of the 
accident. 

In accordance with the FRA requirements for class 3 track, the lAIS had 
inspected the track weekly. On July 20, 1988, the Iowa Department of 
Transportation (DOT), which was responsible for performing FRA oversight 
inspections for Track Safety Standards, conducted a track inspection of the 
lAIS system through the Altoona area between MP 325 and MP 350.8; no defects 
were noted. 

Signals . --Between 1980, when the Chicago, Rock Island, and Pacific 
Railroad declared bankruptcy and ceased operations, and 1984, when the lAIS 
began operations, two other railroads (the CNW and the Iowa Railroad) had 
requested and received authority from the FRA to operate over portions of 
this territory without use of the block signal system. 

The CNW filed a block signal application, in accordance with 49 CFR Part 
235, with the FRA in 1980 and requested that the FRA grant authority for the 
CNW to discontinue the use of the traffic control system between Des Moines 
and Newton, Iowa, and to discontinue the use of the automatic block signal 
system between Newton and Iowa City and between MP 355.6 and MP 351.7 at Des 
Moines, Iowa. The CNW reported that the proposed method of operation was to 
be by timetable and train orders except at Newton and Des Moines where "yard 
limit rules" would apply. Existing train traffic was reported as one 
switching move per day with no following or opposing train movements and with 
no scheduled passenger trains. 

The FRA held a public hearing regarding the CNW's request, and similar 
requests by other railroads, and conducted a field investigation of the CNW 
territory in question. The FRA field investigation report noted that when 
the Chicago, Rock Island, and Pacific Railroad ceased operations all "power 
supply meters" were removed. The report noted further that the signal 
system was well maintained until operations ceased but since that time 
vandalism across the entire area had been extensive, numerous signals had 
been shot out, cases broken into damaging relays, cabinets and wiring and 
that all copper line wires had been stolen with the exception of a few 
isolated areas. Based on the recommendation in the field investigation 
report and the lack of objection in the public hearing, a brief was prepared 
and sent to an internal FRA safety board. The FRA subsequently granted the 
CNW the authority requested. 

When the Iowa Railroad began operations, it also filed a block signal 
application with the FRA in May 1982 requesting authority to discontinue use 
of the automatic block signal system from Des Moines to Iowa City, Iowa, and 
that the approvals granted to the CNW be amended to include the Iowa 
Railroad. The proposed operation was reported to be two trains a day. The 
lAIS also stated to the FRA that when traffic increased the signal system 
would be made operative. No passenger trains were anticipated. The FRA did 
not hold a public hearing on the Iowa Railroad's request (nor was it required 
to) but did conduct a field investigation and prepared a brief that was 



17 

presented to an internal FRA safety board. Based on the information 
presented, the FRA granted the Iowa Railroad temporary approval until 
November 18, 1984. 

Before the Iowa Interstate Railroad began operations in November 1984, 
it requested, in a letter dated October 14, 1984, that the FRA grant 
authority for the lAIS to operate without the use of the existing block 
signal system, and requested further that all previously granted relief for 
the territory from Council Bluffs, Iowa, to Bureau, Illinois, be transferred 
to them. The lAIS did not file a block signal application. lAIS officials 
informed the FRA that their operations would be similar to that of the Iowa 
Railroad and that an application for "permanent discontinuance" of the block 
signal system would be made at a later date. The lAIS Superintendent of 
Operations stated to Safety Board investigators that "...the signals were 
still there, but they were inoperative. They had been vandalized. All of 
the relays and batteries and all the necessary equipment for the signal 
system had been vandalized to a point that it was cost prohibitive to restore 
them...." 

The FRA Associate Administrator for Safety responded to the lAIS on 
November 23, 1984, informing the lAIS that FRA's previous approvals to 
operate without use of the block signal system had been granted on a 
temporary basis. ^ The letter stated further, "...I strongly urge that you 
take immediate steps to make application for FRA approval of whatever action 
you intend to take in the matter of the retention or disposition of the 
signal system on the tracks of the former Chicago, Rock Island, and Pacific 
Railroad between Council Bluffs, Iowa, and Davenport, Iowa " 

The FRA informed the Safety Board that it should not have addressed in 
its letter to the lAIS the need to consider the abandonment of the signal 
system from Des Moines to Newton because the previously granted approval to 
the CNW would have transferred automatically to the lAIS. 

The lAIS provided Safety Board investigators an unsigned copy of a 
letter dated April 14, 1987, in which the lAIS requested that the FRA grant 
the lAIS authority to operate permanently without using the block signal 
system. The lAIS stated that it has not received a response to its letter. 
The FRA Standards Division Chief for Signals informed the Board that the FRA 
has no record of having received a request from the lAIS regarding permanent 
operation without use of the block signal system. 

Safety Board investigators observed that signal No. 3472, located 
approximately 0.3 mile west of the Altoona station (see figure 2), had not 
been removed, covered, or turned away from the track. 



° For the area at Altoona, FRA's approval to the Iowa Railroad to 
operate without the signal system expired on November 18, 1984. 



18 



Train Information 

Extra 406 East . --At the time of the accident, Extra 406 East was a 
cabooseless train that consisted of 67 freight cars and 4 diesel -electric 
locomotive units, with a trailing tonnage of approximately 7,000 tons. All 
the locomotive units of Extra 406 East and the locomotive unit of Extra 470 
West were manufactured by the Electro Motive Division (EMD) of General 
Motors Corporation, were previously owned by the Illinois Central Gulf 
Railroad (ICG), and were rebuilt with a low profile short hood. The lAIS 
does not use event recorders in their locomotive units. 

The lead unit of Extra 405 East was equipped with a new radio unit that 
was being tested by lAIS. Based on statements of the crew of Extra 406 East, 
the radio on their train was operative. 

During the postaccident inspection of locomotive unit 406, the 
controlling locomotive of Extra 406 East, the cab controls and the 26L air 
brake valve were found in the following positions: control stand reverser in 
the forward position; throttle in eighth position; automatic brake valve in 
emergency position; independent brake valve in applied position; the left 
side emergency valve in the closed position; MU-2-A valve in the lead 
position;' and the operating switches in the "on" position. 

Extra 470 West . --When Extra 470 West departed Newton, it consisted of 
one diesel -electric locomotive unit, 3 loaded cars and 5 empty cars.''° It is 
unknown if an initial air brake test was conducted at Newton. 

Postaccident inspection of unit 470, the only locomotive unit of Extra 
470 West, found the automatic brake in the service position with the handle 
broken off, and the MU-2-A valve in the lead position. The throttle stand 
was not located following the accident. Due to the extensive destruction, 
the condition of the air brake valves could not be ascertained. The A-1 



This air brake control valve must be in either the lead or trailing 
position (depending on the location of the locomotive unit, i.e. lead unit or 
trailing unit) for the operation of the independent brake. 



10 



Extra 470 West was configured from the front end as follows; 



locomotive unit, 2 empty covered hoppers, 2 loaded tank cars, 1 loaded 
covered hopper, and 3 empty gondolas. 



19 

charging cut-off pilot valve^^ was removed for inspection and testing. (See 
Tests and Research.) 

With the exception of the hand set, the radio equipment on the 
locomotive unit of Extra 470 West was mounted in the short hood. There is no 
record of radio communications involving Extra 470 West on the day of the 
accident. 

Tank cars ADMX 29477 and ADMX 29494, both U.S. Department of 
Transportation (DOT) specification IIIAIOOWI tank cars, were built in 1985 by 
American Car Foundry (ACF) Industries, Inc. for the Archer Daniels Midland 
Transportation Company (ADM). The tank cars were approved for the 
transportation of ethanol and products authorized in 49 CFR Part 173 for 
which there "are no special commodity requirements. "^2 

Both tank cars had an inside length of 53 feet 10 1/2 inches and an 
inside diameter of 9 feet 11 1/8 inches. The 7/15-inch tank shell of the 
cars was fabricated from Association of American Railroads (AAR) TC-128 Grade 
B tank car steel, and the 15/32-inch tank heads were fabricated from American 
Society for Testing and Materials (ASTM) A-515 Grade 70 steel. The full 
capacity of each shell was 30,000 gallons based on a lading of 29,400 gallons 
and a 2 percent outage^^ of 600 gallons. The AAR design specification 
indicated that the test pressure for the tanks was 100 psig. Each tank car 
was equipped with 100-ton trucks and type E top and bottom shelf couplers. 
The light weights of ADMX 29477 and ADMX 29494 were 67,800 pounds and 67,200 
pounds, respectively. Neither tank car was equipped with head shield 
protection, nor required to be by federal regulations. 



When an emergency application occurs regardless of whether it was 
initiated from the automatic or emergency brake valve, from an undesired 
separation of locomotive units or cars, from the caboose valve or any other 
sources, the A-1 charging cut-off pilot valve responds by going to 
application position where it (1) delivers air pressure to the brake valve 
which immediately cuts off air flow to the brake pipe, (2) delivers air 
pressure to a pressure switch which nullifies dynamic brake, (3) delivers air 
pressure to a pressure switch which causes power to be cut off, (4) and 
delivers air pressure to initiate sanding for a specific time period (if so 
equipped) . 

^^ Based on this regulation, the tank cars could have transported any 
nonregulated commodity or any regulated commodity that does not have any 
special handling requirements, such as insulated tanks or a cargo heating 
system. 

The amount of unfilled volume remaining inside the tank car after the 
tank has been loaded to allow for the product to expand in case of changes in 
theambienttemperature. 



20 

Both tank cars had a top manway entrance with an inside diameter of 
20 inches. A hinged lid covered the manway opening and was secured by 
8 bolts and nuts around the circumference. A vacuum relief valve was mounted 
in the center of the manway lid. The ACF design drawing for the manway 
arrangement specified that the manway gasket be white neoprene, with an 
outside diameter of 21 7/8 inches, an inside diameter of 18 7/8 inches, and a 
thickness of 1/8 inch. The ACF design drawing did not include any 
specifications for gasket hardness or compressibility. ACF also specified 
that Bostick 1142 cement be used to secure the gasket to the cover. 

Both tank cars were also equipped with two pressure relief valves, 
located on each side of the manway, and a bottom outlet valve. The relief 
valves were rated to discharge at 75 psig.'"^ The relief valves on ADMX 29477 
and ADMX 29494 were tested by the manufacturer, Midland Manufacturing 
Corporation (Midland), in September 1985 and October 1985, respectively. 
The test certificate indicates that all four relief valves opened at 75 psig 
and were vapor tight at 60 psig.''^ The test certificate also indicates that 
the tanks were hydrostatically tested at 100 psig without evidence of 
leakage. The president of Midland stated that the two relief valves are 
tested in a vertical position only but that, in the absence of pressure, the 
relief valves should be vapor and liquid tight regardless of the position or 
orientation of the valves with respect to the vertical. The bottom outlet 
valves are designed to function and effectively shut off the flow of liquid 
even if exposed to fire. The manufacturer has stated that these type valves 
are intended for use with flammable and other hazardous materials. The 
bottom outlet valves are rated for absolute pressures to 285 psi and for 
temperatures ranging from -20 degrees F to 500 degrees F. 



^^ Psig - pounds per square inch gage. Gage pressure is the difference 
between the total absolute pressure within a container and atmospheric 
pressure (14.7 pounds per square inch absolute), and measures the magnitude 
of the net pressure exerted on the container. 

^^ As the internal tank pressure increases, the valves are designed to 
start opening at 60 psig and be completely opened at 75 psig. 



21 



Method of Operation 

The lAIS is a regional railroad, ^^ which began operations in November 
1984,''^ The Heartland Corporation,^^ with the assistance of major freight 
shippers who faced uncertainty about continued rail service, acquired certain 
property and trackage rights from the trustees of the estate of the Rock 
Island. The Iowa Interstate Railroad then acquired the right to use this 
property and track through a long-term lease with a fixed buy-out option at 
the end of the lease period, and operations were initiated. 

The lAIS is a nonsignaled (dark) single track, mainline railroad 
operated by timetable, train orders, and special instructions. Trains are 
operated by two crewmembers--an engineer and conductor. lAIS normally 
operates two through trains daily, one in each direction between Blue Island, 
Illinois, and Council Bluffs, Iowa, and local trains that originate at 
various intermediate terminals. The lAIS also operates five branch lines. 
During the investigation, lAIS officials made reference to train operations 
that had been announced for special passenger train excursions over the lAIS. 

The dispatcher's office, located in Iowa City, Iowa, is staffed by one 
dispatcher on each 8-hour shift 24 hours a day who handles the 488 miles of 
railroad between Blue Island and Council Bluffs. 

General orders, general notices, and special instructions are issued by, 
and over the signature of, the Superintendent of Operations. On April 14, 
1987, general order No. 25 was issued to all employees adopting Timetable 
No. 2, dated April 15, 1987, and the General Code of Operating Rules, to be 



^^ Although there is no set definition, a regional railroad is 
considered a railroad larger than a short line railroad (usually with more 
than 200 route miles), but smaller than a Class I railroad and usually 
considered a Class II railroad. Within the last 15 years, approximately 19 
regional railroads have begun operation as newly created railroads or with 
new ownership. 

^^ According to testimony of the president of lAIS, when the lAIS was 
granted authority on October 10, 1984, by the Interstate Commerce Commission 
to conduct operations, the Rock Island lines were being used by tenants (the 
Milwaukee Railroad Company and the Iowa Railroad Company) with short-term 
leases. 

^^ The Heartland Corporation is a holding company controlled by on-line 
shippers and the Cedar Rapids & Iowa City Railroad. The Cedar Rapids & Iowa 
City Railroad is a 50-mile railroad owned by the Iowa Electric Light and 
Power Company. 



22 

effective April 22, 1987.'" On January 1, 1988, general order No. 1 was 
issued outlining changes in the General Code of Operating Rules as they would 
apply on the lAIS. On January 10, 1988, general order No. 10 was issued 
cancelling all general orders Nos. 1 through 70 for 1987 in their entirety. 
According to the lAIS Superintendent of Operations, the General Code of 
Operating Rules, although annulled by general order No. 10, remained in 
effect on the lAIS. 

Rule 93 of the General Code of Operating Rules governs the movement of 
trains within yard limits. Rule 93 states, in part: "...movements within 

yard limits must be made at restricted speed " Restricted speed is 

defined as follows: 

A speed that will permit stopping within one half the range of 
vision; short of train, engine, railroad car, stop signal, derail 
or switch not properly lined, looking out for broken rail, not 
exceeding 20 mph. 

When the engineer of Extra 406 East was asked about the application of rule 
93 and the yard limits at Altoona, he stated, "...I never really thought 
of... how far east of Altoona it [yard limits] went. I knew that we had a 
yard limit rule at Altoona, but I never did know exactly where--how far it 
extended." 

Federal regulations address the designation of yard limits. 49 CFR 
218.35, states, in part: 

(a) After August 1, 1977, yard limits must be designated by-- 

(1) Yard limit signs, and 

(2) Timetable, train orders, or special instructions. 

The dispatcher was able to communicate with trains by radio or by 
crewmembers calling from a wayside telephone. The radio system was a 
repeater type system with transmitters being located at strategic locations 
to facilitate coverage (intended eventually to be complete coverage) of the 
railroad. On the date of the accident, installation of the entire system 
had not yet been completed and "dead spots" (locations where reception was 
poor or nonexistent) existed on some parts of the railroad. Preparatory work 
was in progress for installing a radio repeater transmitter at Altoona to 
improve radio reception in the future. Stations where telephones were 
located, which included Altoona and Newton, were designated in the 
timetable. The crew of Extra 406 East testified that before departing 
Altoona, they did not attempt to radio the dispatcher or Extra 470 West, nor 
were they required to do so by company rules. 



^' Prior to April 22, 1987, the lAIS operated under the Uniform Code of 
Operating Rules, which had been in effect on the former Rock Island property. 



23 

A "standard" clock^^ was located in the enginehouse office at Council 
Bluffs. Rule 3 of the General Code of Operating Rules states, in part: 

Time comparison: the watches of employees designated must be 
compared with a standard clock before commencing each days 
work. . .Conductors must, when practicable, compare time with their 
engineers before starting each trip or days work. 

Although the conductor testified that he compared his watch with the 
standard clock in Council Bluffs, neither crewmember could recall if they 
compared time with each other before commencing the trip. The engineer 
testified that he did not know the location of the standard clock at Council 
Bluffs. 

When asked if anyone was assigned the duty of reporting the times 
trains departed Newton, the assistant superintendent of operations in Newton 
stated, "I think it is. Sometimes I will do it, sometimes the agent does it. 
It's nobody's specific duty." When the dispatcher on duty at the time of the 
accident was asked how dispatchers receive information on the arrival and 
departure times of trains moving over the territory, he stated, "...if 
there's someone on duty at the station. . .they will call in... or else the crew 

will call on the radio " There were no departure times recorded on the 

train sheets for Extra 470 West on July 30, 1988, when it departed Newton, 
its initial terminal. The dispatcher further stated that because train order 

213 "...was a right over order I don't have to follow it [Extra 470 West] 

as carefully." 

Dispatchers are required to maintain a record of train movements, in 
accordance with 49 CFR 228.17, which states, in part: 

(a) each carrier shall keep, for each dispatching district, a 
record, of train movements made under the direction and control of 
a dispatcher who uses telegraph, telephone, radio, or any other 
electrical or mechanical device to dispatch, report, transmit, 
receive, or deliver train orders pertaining to train movements. 

The following information shall be included in the record: (9) 

direction of movement and the time each train passes all reporting 
stations. (10) arrival and departure times of trains at all 
reporting stations. 

Newton and Council Bluffs are designated by the lAIS as reporting stations. 

Rule 521, paragraph 4, of the General Code of Operating Rules requires 
that, before a train order is acted upon, both the conductor and engineer 
must have a written copy of the train order and make certain that the train 
order is read and understood by other members of the crew. 



20 



A clock designated by the railroad as one which provides the correct 



24 

The lAIS had no procedures or rules to require that train order 
operators verify to dispatchers that train orders have been received by 
traincrews. 

Rule 93 of the General Code of Operating Rules also states, in part, 
"Trains must clear other trains which are superior as prescribed by Rules 86 
and S-87." This statement was annulled by rule 7 of the special instructions 
in lAIS timetable No. 2, which read: "Rule 93: 3rd paragraph does not apply." 
The superintendent of operations stated that the third paragraph of rule 93 
had been deleted to enable trains to operate within yard limits without 
concern as to the superiority of trains. Rule S-87 states that "An inferior 
train must clear the main track not less than 5 minutes before the timetable 
schedule leaving time or train order waiting time of an opposing superior 
train." 

The lAIS operates over trackage of the DMU and the CNW between MP 353.2 
and MP 364.5. Special instructions in lAIS timetable No. 2 for the third 
subdivision in which Newton, the home terminal and initial station of crews 
operating over this territory, is located states, in part, "Between MP 350^^ 
and MP 364.5, trains and engines will be governed by timetable and rules of 
the CNW Transportation Co. and DMU R.R. Permission from the CNW yardmaster 
must be obtained before entering these limits. "^2 The lAIS also operates 
over trackage of METRA^^ between Blue Island and Joliet, Illinois, and over 
trackage of the CSX Transportation Company between Joliet and Bureau, 
Illinois. 

Rule 4 (c) of the General Code of Operating Rules states, in part, that 
general orders, bulletins, notices and circulars will be posted in books 
and/or on bulletin boards at stations designated in the timetable. lAIS 
timetable No. 2 designated Newton as a station where general order boards or 
books were located. Current general orders, general notices, and special 
instructions of the CNW were not posted on the bulletin board at Newton. At 
the Safety Board's deposition proceedings, lAIS officers stated that 
information on operations over CNW trackage was now being posted at Newton. 

Company rules and Federal regulations require that when a train is 
originally made up (initial terminal) and when a train consist is changed by 
picking up or setting out cars (intermediate locations), a test of the train 
air brake system must be conducted in accordance with prescribed procedures. 



21 



lAIS officers testified that trackage recently had been acquired by 



the Heartland Corporation from the CNW between MP 350 and MP 353.2. 

? 7 

As noted previously, MP 353.2 and MP 364.5 are, respectively, the 

east end and the west end of CNW's yard at Des Moines. CNW rules govern the 

movement of trains within the yard. CNW had not deleted the third paragraph 

of Rule 93 of the General Code of Operating Rules. 



23 



METRA is the former Northeast Illinois Railroad Corporation now under 



the authority of the Chicago Commuter Rail Service Board. 



25 

(See appendix D.) The conductor of Extra 406 East testified that an 
initial terminal air brake test of the train had been performed by the 
switchcrew at Council Bluffs, and that the enginecrew had received a written 
note to that effect before they departed. He further stated that no tests 
were made after they coupled the locomotive units to the train at that 
location. The crew of Extra 406 East testified that no air brake tests were 
performed at any of the locations where cars were set out or picked up en 
route from Council Bluffs to Altoona. 

The positioning of tank cars within a train is addressed in 49 CFR 
174.91, which states, in part: 



Except for a tank car placarded "COMBUSTIBLE, "2^ a loaded placarded 
tank car in a moving or standing train may not be nearer than the 
sixth car from the engine, occupied caboose, or passenger car. 
When the length of the train will not permit a loaded placarded car 
to be so placed, the tank car must be placed as near the middle of 
the train as possible, and not nearer than the second car from the 
engine, occupied caboose, or passenger car. 

The lAIS had included the requirement of 49 CFR 174.91 in the special 
instructions in timetable No. 2 that was in effect at the time of the 
accident. (See appendix C.) 

Both the superintendent of operations and an assistant superintendent of 
operations assigned to the Newton yard stated that based on their 
understanding of rules the two tank cars should have been positioned as the 
sixth and seventh cars behind the locomotive, i .e. , the last two cars of the 
train. 

Personnel Information 

Extra 406 East . --The engineer of Extra 406 East had been off duty from 
Monday evening, July 25, through Thursday, July 28, and spent the last day 
working on a family construction project. He slept between 10:30 p.m. 
Thursday and 5:00 a.m. Friday. The engineer stated that he usually worked 
from "8 in the morning until five or six." 

The conductor of Extra 406 East had been off duty on Thursday, July 28, 
and spent the day at home performing various chores. He reported that he 
went to bed at 9:30 p.m. that evening and slept well until 5 a.m. the 
following morning. 

Both the engineer and conductor of Extra 406 East reported for duty at 
7 a.m. on July 29, 1988, and worked a 10 1/2-hour shift on an extra train 



There are no placement or separation criteria in the Federal 
regulations for tank cars placarded as "COMBUSTIBLE." 



26 

movement before going off duty at 5:30 p.m. in Council Bluffs, where they 
each were provided a hotel room. The engineer and conductor stated that 
after eating dinner they slept a maximum of 5 and 4 hours, respectively, 
before being called by the lAIS dispatcher at 12:30 a.m. to report for duty 
at 1:30 a.m. for a return trip to Newton. They had been on duty for about 
10 hours when the accident occurred. When the engineer was asked after the 
accident what time he thought they would have finished up on the day of the 
accident, he stated, "I figured our 12 hours would be close. It would be 
after one." 

When the engineer was asked after the accident about being tired or 
fatigued, he stated, "I'm not used to staying awake all night, I was tired 
but not — ." When asked if either he or the conductor had been tired enough 
to nod off or to actually show the signs of fatigue, he replied, "He [the 
conductor] might have nodded off but not sleep. I remember looking over 
there and you could see his head bobbing. . .but he never slept, no." The 
conductor stated that he "wasn't really tired, no" and that he didn't have 
any trouble staying awake. 

The engineer of Extra 406 East had 23 years of experience in railroad 
operations having been employed by the Rock Island and the CNW as a brakeman 
and conductor. He was hired by the lAIS in November 1986 as a part-time 
conductor and worked in that position until January 6, 1988, when he became a 
full-time conductor. According to lAIS training records, he began training 
for the position of locomotive engineer in January 1988 and was promoted to 
engineer on July 25, 1988, 5 days before the accident. (See additional 
discussion under Training Program for Engineers.) 

The conductor of Extra 406 East had 32 years of experience in railroad 
operations, of which 23 years were as a conductor. He had been employed 
previously by the Rock Island and the Iowa Railroad as a brakeman and 
conductor. 

Extra 470 West . --The engineer and conductor of Extra 470 West reported 
for work at 7 a.m. on July 29, and returned to their homes at 6 and 7 p.m., 
respectively, that evening. Each reportedly had slept about 8 hours during 
the night before the accident. On the day of the accident, they reported for 
duty at 8 a.m. at Newton and operated Extra 470 West until the time of the 
accident. 

The engineer of Extra 470 West had more than 8 years of experience in 
railroad operations. Prior to being hired by the lAIS on October 25, 1986, 
as an engineer/conductor, he had been employed as an engineer with the Rock 
Island. 

The conductor of Extra 470 West had 28 years of experience in railroad 
operations. He had been employed previously in the positions of track 
laborer, brakeman, and conductor by the CNW and as a conductor by the Rock 
Island. 



27 

Based on their experience with the Rock Island, the operating crews of 
Extra 406 East and Extra 470 West were considered by the lAIS superintendent 
of operations to be qualified for their respective positions. 

Other lAIS Personnel .--The chief dispatcher on duty at the time of the 
accident was initially hired by the lAIS as a dispatcher in November 1984. 
He had no prior experience as a dispatcher but had worked part-time as a 
clerk with the Iowa Railroad for 4 months during the summer of 1983 before 
returning to school. When he began employment with the lAIS, he received no 
formal training on the duties of dispatcher. In addition to issuing train 
orders, the chief dispatcher issues general orders according to the 
superintendents' instructions and performs various clerical duties. He 
attended the rules class in April 1987 and was qualified on the General Code 
of Operating Rules. 

The assistant superintendent of operations at Newton was employed with 
the lAIS in October 1984. He had been employed previously by the Rock Island 
and had more than 20 years of experience working as a brakeman and conductor. 
On the day of the accident, he performed the duties of a train order operator 
at Newton in addition to his regular duties. He was qualified on the General 
Code of Operating Rules, according to the superintendent of operations. 
(See appendix B.) 

Training of Operating Employees 

Operating Rules Classes . --The lAIS conducted training classes on the 
operating rules for its employees in April 1987, before issuing general 
order No. 26 for use of the General Code of Operating Rules and Timetable No. 
2. There is no record that the company had conducted training on operating 
rules prior to April 1987. Based on the information provided by the lAIS, 70 
percent of its operating employees attended the classes in April 1987; all 
those who attended the classes completed successfully what the railroad calls 
an "oral examination" on the General Code of Operating Rules. The 
superintendent of operations stated that questions for the "oral 
examinations" were randomly chosen and posed to the class as a whole and were 
discussed by the group. No written examinations were conducted. Although 
requested by the Safety Board, the lAIS did not provide any documentation on 
instructions given to the various rules examiners on how to conduct rules 
classes. There is no record of training or examination on the operating 
rules for the remaining 30 percent of the employees listed on the roster. 

The engineer and conductor of Extra 406 East and the engineer of Extra 
470 West attended the rules classes in April 1987; the conductor of Extra 470 
West was hired after that date and received no training on the lAIS operating 
rules before he began working on the railroad. With the exception of the 
engineer of Extra 406 East (see Training Program for Engineers), there is no 
record of the other crewmembers receiving any other type of training. 

The superintendent of operations stated that when the lAIS began 
operations the railroad had adopted the "Rules and Instructions for Train 
Handling and Operation of Air Brakes," which had been in effect on the 
former Rock Island since 1974 and that no updates had been made to that 



28 

document. He stated further that the train and engine crews had received 
copies of the manual while formerly employed with the Rock Island, and he 
assumed that they had retained their copies of the manual. Testimony from 
the crew of Extra 406 East indicated, however, that all traincrews did not 
have copies of the manual. There was no record that these rules and 
instructions had been adopted in writing. The superintendent of operations 
stated that the rules in the manual were taught in the rules classes. 
Instructions in the manual for performing the proper train air brake tests 
are consistent with the provisions for conducting air brake tests required in 
49 CFR Part 232. The instructions in the manual, however, do not address 
conducting air brake tests with an end-of-train device in cabooseless 
operations. 

Training Program for Engineers . --The superintendent of operations stated 
that in November 1985 the lAIS implemented a formal program, which had been 
patterned after one used on the former Rock Island, for the promotion of 
operating employees from the position of conductors to the position of 
locomotive engineers. The program begins with a 1-day classroom 
indoctrination, followed by three phases of on-the-job training (OJT) during 
which various aspects of locomotive operations are addressed. A 1-day 
classroom session is held following each phase to prepare the student 
engineer for the next phase and the final examination. The program is to be 
completed within 6 months, but the timeframe may be shortened depending on 
the student engineer's previous experience and progress during training. 

During the three phases of OJT, the student engineer is assigned to the 
crew as the conductor and is responsible for performing the duties of that 
position while simultaneously receiving instruction on the position of 
engineer. According to the superintendent of operations, it is the policy of 
the lAIS to have each train crewmember qualified as both conductor and 
engineer. The superintendent of operations stated that this practice is 
advantageous because it reduces the number of employees required for train 
operations and that at the time of the accident, 80 percent of the operating 
personnel were qualified for both positions. He stated further that all 
engineers on the lAIS could be assigned to serve as an instructor for a 
student engineer. He further stated that the instructors were provided with 
"a guideline. . .they should use" during the training. Two engineers who had 
served as instructors for the engineer of Extra 406 East testified that they 
had not been given any guidance or instructions as to what material should be 
covered during the training program before the accident. One of the 
engineers stated that he received the booklet on the training program 3 to 4 
weeks before the Safety Board's deposition proceedings, which were held on 
November 11, 1988. 

According to the training program, the assistant superintendent of 
operations is required to make at least one trip with each student engineer 
during each phase of the training to evaluate personally the progress of the 
student engineer. The assistant superintendent of operations is required 
further to certify that each student engineer is qualified to function as an 
engineer. This certification and the successful completion of two written 
examinations--one on mechanical and air brake subjects and one on operating. 



29 

safety and radio rules--are mandatory, according to the program, before a 
candidate can be promoted to the position of engineer. 

The engineer of Extra 405 East entered the engineer training program in 
January 1988. His training records indicate that he served as a conductor on 
a yard switch engine assignment between January and May 1988. According to 
the engineer, there were few occasions he experienced over-the-road training 
from another engineer because "my job for the first 6 months was there in the 

Newton yard just switching " In yard operations, the conductor has many 

duties and is often off the train performing switching operations. He stated 
that he was not evaluated by a supervisor or company official during this 
period of training. Although required by the program, there is no document 
certifying that he was qualified to be promoted to the position of engineer. 
The assistant superintendent of operations stated that he had not personally 
certified that the engineer of Extra 406 East was qualified and that he had 
never certified for promotion any trainee he supervised. 

The superintendent of operations testified that the assistant 
superintendent of operations, who, according to the program, was responsible 
for evaluating the performance of the student engineers, was not a qualified 
engineer on the lAIS. 

The engineer of Extra 406 East completed successfully a written 
examination on July 25, 1988, which also served as an operating rules 
examination, according to the superintendent of operations. Based on this 
examination and the observations of other engineers, the superintendent of 
operations, without ever accompanying the engineer of Extra 406 East, 
promoted him to the position of engineer on July 25, 1988. According to one 
of the instructors, the trains handled by the engineer of Extra 406 East 
during his training program were, on the average, 17 to 25 cars in length 
with a trailing tonnage of about 1,800 tons. The accident occurred during 
the first road trip and the second train movement to which the engineer had 
been assigned following his completion of training and promotion to 
locomotive engineer. 

Operating Rules of the CNW .--The superintendent of operations of the 
lAIS stated that operating crews had been qualified on CNW rules to operate 
over trackage of the CNW at Des Moines. The engineer of Extra 406 East 
stated that he had not been qualified by a company official to operate over 
CNW trackage. The transportation superintendent of the CNW informed the 
Safety Board that an lAIS officer had been qualified as a rules examiner on 
the CNW rules. The Safety Board requested a list of lAIS employees qualified 
on the CNW rules and the date and method by which they were qualified, and 
the name of the company official qualifying lAIS employees on the CNW 
operating rules. The lAIS has not provided this information. 

Management Oversight 

The assistant superintendent of operations stated that it was company 
policy not to conduct efficiency testing. lAIS officers stated that they did 
not perform operational tests and inspections for various reasons: 1) "when 
the lAIS applied with the Interstate Commerce Commission, we did not indicate 



30 

we would do operational testing; 2) the company had waivers from the ICC and 
the FRA permitting the lAIS not to perform operational tests; and 3) the 
company has historically been exempt from 49 CFR Part 217.9 pursuant to Part 
217.13." The lAIS could not provide documentation for an exemption or waiver. 
(See further discussion under Federal Regulations and FRA Oversight.) 

Testimony from operating employees indicated that very little on-line 
supervision of the day-to-day operations of train and enginecrews outside the 
terminals was provided and that supervisors rarely rode trains. There were 
11 supervisors for 78 train and enginemen scattered over approximately 488 
miles of railroad, and the supervisors were often required to perform the 
duties of operating personnel. The position of road foreman of engines, who 
is responsible for overseeing enginecrew operations, was vacant at the time 
of the accident. According to the assistant superintendent of operations, 
this position had been vacant since "shortly after the first of the year 
[1988]." 

A review of the lAIS personnel records of the employees involved in this 
accident indicated that only the chief dispatcher and the conductor of Extra 
406 East had a prior record of disciplinary action while employed by the 
lAIS. The chief dispatcher was issued a letter of reprimand in October 1986, 
for accepting a transfer of train orders that failed to give a train order 
(running order) to a train on September 26, 1986, between Newton and 
Atlantic. The conductor was issued two letters of reprimand: one in October 
1986 for operating a train from Newton to Atlantic without a train order 
(running order) on September 26, 1986, and one in December 1987, which 
described and cited his failure to obey a wait order on December 14, 1987, 
8 months before the accident. According to the superintendent of operations, 
the lAIS policy regarding disciplinary action was that three letters of 
reprimand could constitute grounds for dismissal. 

Federal Activity 

Federal Oversight. --The provisions of 49 CFR Part 217 require each 
railroad (1) to file a copy of its operating rules, timetables, and timetable 
instructions and any amendments to these documents, (2) to file a program for 
conducting operational tests and inspections to determine compliance with 
operating rules, timetables, and timetable instructions, and (3) to file a 
program of instruction on operating rules. Furthermore, each railroad, 
except for a railroad with fewer than 400,000 manhours, is required to file 
annually with the FRA a report on these activities for the previous year. 
(See appendix E.) 

On September 7, 1988, a Safety Board investigator was informed by FRA 
personnel of the Operations Practice Division that the lAIS (1) did not have 
a rule book on file, (2) did not have an operating procedure and inspection 
plan on file, and (3) had reported over 400,000 manhours for 1987. 

Information obtained from the FRA indicated that on October 24, 1986, at 
the Council Bluffs yard, an FRA inspector noted a defect on an inspection 
report with regard to 49 CFR Part 217, with the remark which stated, in part: 



31 

Check train orders, general orders, rules books (none 
available) safety, rules book timetable (none 
available) [superintendent of operations] advised had 
ordered rule books and is printing new timetable 

Information obtained from the FRA's Headquarters System Support Division 
indicated that on September 2, 1987, at Blue Island, Illinois, an FRA 
inspector noted defects on an inspection report with regard to 49 CFR 217.9 
and that he found, through discussion with company officials, that the lAIS 
did not periodically conduct operational tests and inspections to determine 
the extent of compliance with its code of operating rules, timetable, and 
timetable special instructions. During the Safety Board's deposition 
proceedings, the lAIS claimed no knowledge of the report filed on 
September 2, 1987. According to the FRA, a defect on an inspection report 
only indicates that an FRA inspector took exception to some aspect of the 
carrier's operations; there is no fine imposed or violation reported at that 
time. The FRA indicated further that an inspector can note a defect on an 
inspection report rather than a violation, if in his opinion, a violation is 
not warranted. 

On August 2, 1988, an FRA field inspector filed a report on the lAIS 
with the following remarks: 

Dispatcher's records of train movements failed to show 
weather condition at 6-hour intervals. 

Dispatcher's record of train movements failed to show 
departure time of train at a reporting station. 

Dispatcher's record of train movements failed to show 
unusual events affecting movement of trains including the 
head end collision of Extra 406 West and Extra 470 East 
on July 30, 1988. 

Discussions with FRA field and headquarters personnel indicate that FRA 
personnel differ on what action takes place after field personnel notes 
defects on inspection reports. Field personnel indicated that for a 
violation to be levied, action would have to be initiated by headquarters 
personnel. Headquarters personnel indicated that defects do not result in 
enforcement action; violations are recommended by the field personnel and 
then evaluated at headquarters for sufficiency of legal basis to enforce the 
violation. Based on FRA records, the lAIS has never been cited for a 
violation of operating practices or had a penalty imposed. 

On December 7, 1988, the Safety Board wrote to the FRA's Associate 
Administrator for Safety and requested specific information regarding the 
lAIS' compliance with 49 CFR Part 217 and any action contemplated by the FRA 
to assure compliance. (See appendix F.) 

In a letter dated January 18, 1989, the FRA responded to the Safety 
Board's letter concerning the lAIS' compliance with 49 CFR Part 217. The FRA 
stated that (1) the lAIS had not been granted an exemption or waiver from the 



32 

provisions of 49 CFR Part 217 which addresses railroad operating rules, 
(2) the lAIS was not in compliance with 49 CFR Part 217, (3) the lAIS has not 
petitioned for an exemption from 49 CFR Part 217, (4) the lAIS did file a 
copy of its operating rules, as required by 49 CFR 217.7, and (5) the lAIS 
has not filed a program of instructions on operting rules, as required by 
49 CFR 217.11. With respect to filing a program of operational tests and 
inspections, as required by 49 CFR 217.9, the FRA stated that the "lAIS, in 
December 1988, filed a program of operational tests and inspections with the 
FRA's Washington, D.C., Office of Safety." With respect to filing an annual 
report, as required by 49 CFR 217.13, the FRA stated that an annual "report 
was filed but not in a timely manner." In response to the Board's question 
as to how the defect that was filed in September 1987 was resolved, the FRA 
stated that "Carrier officials were admonished to bring the lAIS programs 
required under 49 CFR 217 into compliance." The FRA stated further that it 
"has initiated an enforcement action against the lAIS through the procedures 
of the Federal Claims Collection Act." 

FRA headquarters personnel told Safety Board investigators that the FRA 
relies, primarily, on its field staff to determine if defects noted on 
inspection reports have been corrected by the carriers. The FRA also relies 
heavily on its district and regional personnel to notice trends that indicate 
a particular carrier may need special attention. Defects and violations 
noted on inspection reports are entered into a computer data base. However, 
the FRA does not have a formal process for the systematic evaluation of this 
data base. According to FRA, ad hoc reviews of portions of the data base are 
occasionally performed. 

Accident Reporting Criteria and Previous Accidents . --The National 
Transportation Safety Board's rules pertaining to notification of railroad 
accidents are outlined in 49 CFR Part 840. (See appendix G.) By a final 
rule published in the Federal Register on December 6, 1988, the Safety Board 
amended Section 840.3 to reduce the period of time during which notification 
of certain railroad accidents is mandatory: 2 hours for any accident that 
results in a fatality or serious injury to two or more crewmembers or 
passengers, the emergency evacuation of a passenger train, or the release of 
hazardous materials; and 4 hours for any accident that requires an 
evaluation of property damage. ^^ The rule change became effective on 
February 6, 1989. Prior to that date, a 6-hour limit was in effect. 

Under 49 CFR 171.16, each carrier that transports hazardous materials 
must submit within 15 days to the Research and Special Programs 
Administration (RSPA) of the U.S. DOT a written report about each 
transportation incident that involves the unintentional release of hazardous 
materials and meets other criteria, including property damage exceeding 
$50,000. 



^^ Notification to the National Transportation Safety Board is through a 
toll free telephone number of the National Response Center (800 424-0201). 



33 

FRA accident/incident reporting criteria are addressed at 49 CFR Part 
225. (See appendix H.) 

In addition to the accident at Altoona on July 30, 1988, four other rail 
equipment accidents in which damages exceeded $150,000.00, as reported by the 
lAIS, have occurred on the lAIS since it began operation. These accidents 
occurred on May 8, 1987; August 2, 1987; May 12, 1988; and May 20, 1988. In 
the accident on May 20, 1988, six tank cars transporting alcohol derailed and 
two released product. Although each of the four accidents met the Safety 
Board's accident notification criteria, the Board was not notified of any of 
the accidents. The chief operating officer of the lAIS stated that he was 
not aware of the Safety Board's accident notification criteria. 

The lAIS did file an FRA rail equipment incident report for the accident 
at Altoona on July 30, 1988, and for each of the four previous accidents on 
its property. The incident report submitted by lAIS for the accidents on 
July 30, 1988, and on May 20, 1988, indicated that hazardous materials were 
involved. However, the FRA's computer generated report on the accident of 
May 20, 1988, did not indicate that hazardous materials were involved. 

RSPA informed the Safety Board that the required reports were not 
received for either the accident on May 20, 1988, or the accident at Altoona 
on July 30, 1988, both of which involved the release of hazardous materials. 

The chief operating officer of the lAIS stated that the company official 
responsible for filing reports to the FRA is also responsible for filing any 
hazardous materials incident reports. In a certified letter dated November 
7, 1988, the Safety Board requested that the lAIS submit copies of written 
company procedures for reporting hazardous materials incidents. The Safety 
Board also requested information on the qualifications of the individual 
responsible for reporting the hazarous materials incidents. The Safety Board 
did not receive a response from the lAIS. 

Testimony of the chief dispatcher indicated that there were no written 
procedures or list of numbers to call in the event of an accident. His 
statement further indicated that on the day of the accident, he believed that 
he was calling the FRA to notify that agency of the accident, when, in fact, 
he was calling the National Response Center. The chief dispatcher stated 
that he now has a "list of numbers to call" in the event of an accident. 

Between April 1983 and April 1988, RSPA received from various carriers 
27 reports of hazardous materials incidents in which tank cars shipped by ADM 
have released hazardous materials. The failure in 26 of these reports was 
attributed to either loose or defective fittings. ADM's Cedar Rapids plant, 
the shipper of record for ADMX 29477 and ADMX 29494, was the shipper in 3 of 
the 26 incident reports. 

ADM's plant manager in Cedar Rapids stated that he has not received any 
formal notification from any carrier about problems with tank cars loaded at 
Cedar Rapids. The superintendent of alcohol production at the Cedar Rapids 
plant stated that he had been notified by some carriers about leaking valves 
and fittings on tank cars released from the Cedar Rapids plant but indicated 



34 

that the problems usually are with "older cars that had the top valves [top 
operated bottom valve] on them." He also mentioned problems with bottom 
valves, but stated he had no knowledge of carriers refusing to accept a tank 
car because the manway bolts were not tightened. 

lAIS did not contact ADM about the accident on July 30, until the 
following day after a Safety Board investigator suggested that the railroad 
do so. 

Meteorological Information 

At 11:52 a.m., on July 30, 1988, at the Des Moines, Iowa international 
airport, it was sunny with a temperature of 91 degrees F. Winds were west to 
southwest at 7 to 8 mph. Visibility was reported to be 12 miles. 

Medical and Toxicological Information 

The conductor of Extra 406 East sustained a laceration to the bridge of 
his nose. He was admitted and later released from the hospital on July 30, 
1988. The engineer of Extra 406 East sustained several abrasions on his 
right arm when he jumped from the locomotive just prior to the collision. 

The medical examiner's office performed autopsies on August 1, 1988, on 
the operating crew of Extra 470 West. The report noted compression crushing 
and blunt traumatic injuries for both crewmembers. The report also noted 
"moderate decomposition" and "moderately advanced decomposition" for the 
bodies of the engineer and conductor, respectively. The bodies were not 
recovered until about 5 p.m. on August 1, more than 48 hours after the 
accident. 

Toxicological specimens of blood and urine were obtained from the 
crewmembers of Extra 406 East approximately 4 hours after the accident. The 
samples were obtained under current FRA requirements and were forwarded to, 
and examined by, the Center for Human Toxicology (CHT), Salt Lake City, Utah, 
for the FRA. No alcohol or other drugs were detected in any of the 
specimens. 

Tissue specimens were obtained from the bodies of the deceased 
crewmembers of Extra 470 West by the medical examiner two days after the 
accident. These samples also were forwarded to CHT for examination. Ethanol 
was detected by CHT in the samples of both crewmembers; no other drugs were 
detected. According to CHT, the ethanol was a result of bacterial 
contamination. 

Neither the dispatcher nor the train order operator on duty at the time 
of the accident were requested to submit to toxicological testing. 

Survival Aspects 

Unit 406, the lead unit of Extra 406 East, which was operating eastbound 
with its short hood forward, overrode the lead unit of Extra 470 West, which 



35 

was operating westbound with its long hood forward. As a result, the fuel 
tank on unit 406 was damaged. With the exception of slight deformation to 
the rear cab door, the cab compartment structure remained intact. The 
postcollision fire, however, destroyed the interior of the cab compartment. 

The covered hopper car immediately behind unit 470 slipped by the 
standard type E (nonshelf) coupler used to couple the car to the locomotive 
and it overrode the short hood end of unit 470 and destroyed the cab and all 
the associated equipment at that end of the locomotive. 

Transportation of Hazardous Materials 

Tank Car Design Standards . --U.S. DOT design specifications for tank cars 
are contained in 49 CFR Part 179. Under 49 CFR 179.3, the AAR Committee on 
Tank Cars has been delegated by the DOT to approve applications for the 
design and construction of tank cars, when "in the opinion of the Committee," 
the tanks and equipment are in compliance with the effective regulations and 
specifications of the DOT. 

49 CFR Part 179 addresses several tank design details such as tank shell 
thickness; however, it does not require that closure fittings maintain their 
integrity in accident situations. For example, there are no standards such 
as minimum torque values and gasket specifications to assure that bolted 
fittings are made liquid and vapor tight. The regulations also do not 
require the AAR or the tank manufacturer to consider and provide protection 
against the internal dynamic loads (from liquid surging or sloshing, for 
example) to which a tank and its fittings may be subjected during a 
derailment or overturn. A tank car engineer at ACF Industries, the builder 
of ADMX 29477 and ADMX 29494, has stated that ACF does not have the expertise 
to "readily" calculate pressures from the dynamic loads that could have 
occurred in this accident. 

Product Shipping Information . --ADMX 29477 and ADMX 29494 were loaded 
with 29,104 and 29,105 gallons, respectively, of denatured ethyl alcohol at 
the ADM plant in Cedar Rapids, Iowa, on July 28, 1988. The tank cars were 
then transported by the Cedar Rapids and Iowa City Railroad (CRANDIC) from 
Cedar Rapids to Iowa City for interchange and transfer to the lAIS. 

The shipping papers for both tank cars identified the product as 
"Denatured alcohol. Flammable liquid, NA 1986 - Ethyl alcohol, anhydrous, 
denatured in part with petroleum products/chemicals content not to exceed 
5%." The shipping papers also indicated that the tank cars were to have 
"Flammable" placards. Both tank cars had a flammable liquid placard bearing 
the number "1986" on each end and side of the tank car. 

The denatured ethyl alcohol loaded in the two tank cars was a mixture of 
ethyl alcohol and gasoline. The concentration of the gasoline was not to 
exceed 5 percent. The denatured ethyl alcohol has a flash point of 58 
degrees F to 60 degrees F. The Emergency Action Guides published by the AAR 
state that for pure ethyl alcohol: 



36 

Ethyl alcohol and its solutions can be easily ignited under 
warm ambient temperature conditions. 

Vapors may travel some distance to a source of ignition and 
flash back. 

Containers have some potential to rupture violently if exposed 
to fire or excessive heat for sufficient time duration. 

Ethyl alcohol does not react with water and is stable in 
normal transportation. 

Ethyl alcohol is generally considered to be of low toxicity. 

Tank Car Securement Procedures at the ADM Cedar Rapids Plant . --The ADM 
plant in Cedar Rapids produces denatured ethyl alcohol, carbon dioxide, 
fructose, and other by-products of corn. The plant manager indicated that of 
the products produced, only the denatured alcohol and the carbon dioxide are 
hazardous materials under Federal transportation regulations. 

At the Cedar Rapids plant, alcohol tank cars are loaded by operators who 
work under the supervision of a foreman. The foreman stated that his 
responsibilities include operating equipment, and overseeing the loading and 
the preparation for transportation of the denatured alcohol. The foreman 
estimated that he spends about 2 percent of his time at the alcohol loading 
facility, and will only "go down to the loading facility if the loader has a 
problem." The superintendent, who is responsible to the plant manager, has 
the overall responsibility for alcohol production, including the loading of 
the alcohol into tank cars. 

The plant manager oversees all plant operations and reports to the 
individual in ADM's corporate office who is responsible for production and 
engineering at ADM's corn processing facilities. The plant manager also 
stated that the only direction given by the corporate office concerning 
loading operations was when the plant originally started production. The 
plant manager indicated that the directions might have been in writing, 
although he had no recollection or written record of the directions. 

In addition to the Cedar Rapids plant, three other ADM plants produce 
denatured alcohol. The plant manager stated that the four plants are 
individually run. He did not know how the corporate office ensures that the 
individual plants employ consistent safety practices. 

When the accident occurred, the only written directives concerning 
alcohol tank car loading operations at the Cedar Rapids plant were two 
interoffice memos from the superintendent to the operators and the foremen. 
The first memo, dated March 27, 1985, concerned the outage required for 
alcohol tank cars. The second memo dated December 9, 1985, contained 
instructions to the operators and foremen concerning loading procedures, and 
states in part; 

Follow all safety regulations while loading. 



37 

Manway and outlet cap must be tight with no leakage. 

Tank car must be properly sealed; bottom valve handle and 
manway. 

Both memos were posted for the operators and foremen in their work areas. 

The superintendent stated that most instructions concerning the loading 
of tank cars had been given verbally. ADM submitted step-by-step written 
loading procedures after the accident and after the Safety Board requested 
that copies of written procedures be submitted. ADM officers stated that 
although the loading procedures were not in written form before the accident, 
these procedures had been followed at the Cedar Rapids plant since 1980. ADM 
also stated that the procedures were written down only because the Safety 
Board had requested that written procedures be submitted, and not because 
these procedures needed to be in writing. 

The step-by-step procedures list the tasks that an operator must 
complete when loading an alcohol tank car but do not provide direction as to 
how a particular task should be completed. The procedures state, in part: 

Open top manway. Check 3/4 inch unload vent to be sure 
it is closed. 

Check bottom for leaks periodically while filling. 

When full be sure pump has shut off before removing 
spout. Check gasket for top and close lid. Tighten 
bolts evenly for proper fit of lid to sealing gasket. 

Seal top manway. Close drop gate from platform and print 
out weight on ticket. 

Remove ground cables and turn placards on rail cars to 
full side. 

The ADM operator who loaded ADMX 29477 and ADMX 29494 on July 28 had 
been employed in the position about 2 1/2 years and had been employed by ADM 
for 14 years. He stated that he has loaded rail tank cars only and that he 
loads a maximum of two cars at one time. He estimated that during his shift 
he may load an average of two to four tank cars with alcohol or carbon 
dioxide. However, if there are no tank cars to be loaded, he is assigned to 
other work. 

The superintendent stated that operators have been instructed orally to 
replace a manway gasket if they questioned whether a gasket is "good or 
bad," and specifically if the gasket shows evidence of weather-related 
cracking. The operator who loaded the tank cars involved in the accident 
stated that while gaskets were changed frequently, he could not specify how 
often. 



38 

Before the accident, ADM did not maintain written records on manway 
gasket replacements or other routine maintenance. According to ADM 
officers, since the accident, the Cedar Rapids plant has started to maintain 
a written log to record when manway gaskets are replaced and other routine 
maintenance work is performed on the alcohol tank cars. ADM stated that it 
does not concede to a need for recording the replacement of gaskets or other 
"routine, minor maintenance work," but has implemented the recordkeeping 
procedure at Cedar Rapids "as a result of the NTSB's investigation." 

The operator stated that after loading a tank car, he inspects and 
replaces the manway gasket if necessary, closes the manway cover, and 
tightens the bolts using a 24-inch wrench. He secures the manway cover by 
tightening the bolts in pairs, starting with the bolts opposite the hinge, 
proceeding to the bolts on either side of the hinge, and then to the bolts on 
the side. The operator stated that the procedure for tightening bolts was 
"known knowledge of tightening anything down." He does not use a torque 
wrench to tighten the bolts to a specified torque but tightens the bolts 
until he cannot tighten them further. After tightening the manway opening, 
he places a seal^^ on the manway. He then replaces the cap for the bottom 
outlet valve and also places a seal on the valve. 

The foreman indicated that the operator was the only ADM employee with 
the responsibility to inspect the manway or the valves of a tank car before 
the tank car is released to the railroad. The superintendent stated that 
neither he nor the foreman follow up with the operators to determine that 
manway gaskets are being replaced when they should. The superintendent 
further stated that he observes the operators on a continuous basis and that 
he depends upon the competency of the operator and the foreman to ensure that 
tank cars are properly prepared for shipment. 

Title 49 CFR 173.1(b) states that it is the responsibility of each 
person who offers hazardous materials for transportation to instruct each 
agent, officer, or employee having any responsibility for preparing 
hazardous materials for shipment as to the applicable regulations. Section 
173.31(b) states that when tank cars are loaded and prior to shipping, the 
shipper must determine that the tank, safety appurtenances, and fittings are 
in proper condition for the safe transportation of the lading. Section 
173.31(b)(3) requires that all closures of openings in tank cars and of their 
protective housings must be properly secured in place. Manway covers must be 
made tight against leakage of vapor and liquid, by use of gaskets of suitable 
materials. All closures of openings in tank cars must be inspected to the 
extent practical for corrosion of or damage to the gasket seating surface. 

Initial training and qualification of ADM operators is accomplished 
through OJT which lasts 6 to 8 weeks. Trainees work with different qualified 
operators during the training period. To qualify for the position of 
operator, the trainees must pass an oral evaluation and test on an operator's 
duties, including those involving tank loading operations, administered by 



leakage. 



39 

the superintendent. Once operators are considered qualified, they are not 
required to requalify for the position or take any recurrent training. 

Tests and Research 

Sight Distance Tests . --Sight distance tests were performed from 11:30 
a.m. to 1 p.m. on August 4, 1988. The tests were performed using two lAIS 
locomotives operated in configurations to represent Extra 406 East (short 
hood forward) and Extra 470 West (long hood forward). Distance to the long 
end and to the short end of the locomotive from the cab is 46 feet and 14 
feet, respectively. The locomotives were operated by two lAIS management 
employees. Representatives from the Safety Board, the FRA, the United 
Transportation Union (UTU), and the lAIS were present in the operating 
compartment of the locomotives. A UTU representative, who was an lAIS 
engineer and was familiar with and had frequently operated through this area, 
was positioned in the conductor's seat of the locomotive representing Extra 
470 West. 

Before any equipment was removed from the scene of the accident, 
investigators established that the point of impact, based on the physical 
evidence, was at MP 346.1. 

The fire that followed the accident destroyed the ground cover and 
foliage in the area of the impact, and the cleanup operation resulted in the 
removal of some of the embankment on the north side of the track. An lAIS 
green hy-rail van was positioned near the point of impact, on the north side 
of the track, to simulate the visual obstruction that the embankment and 
foliage might have presented to the crewmembers of the trains involved in the 
accident. 

Four tests were conducted to approximate the available sight distance 
between locomotives. The first two tests were conducted having the 
locomotives slowly and simultaneously back away from the point of impact. 
The last two tests were conducted with both locomotives slowly approaching 
each other after having first backed out of sight of the other, each to a 
point about 650 to 700 feet from the point of impact. The minimum distance 
between the locomotives that was measured during the four tests was 
1,016 feet. 

A-1 Charging Cut-Off Pilot Valve . --On October 18, 1988, the A-1 charging 
cut-off valve, which had been removed from the locomotive unit of Extra 470 
West, was taken to the manufacturer, Westinghouse Air Brake, in Wilmerding, 
Pennsylvania, for postaccident testing and inspection, in accordance with 
the manufacturer's Test Specification T-2617-0, dated January 26, 1988. The 
testing and inspection determined that the valve was functioning as designed 
and that Extra 470 West experienced an emergency application of the train 
line air brakes as a result of a "break-in-two," or train line separation, 
and not as a result of an emergency application by the head-end crew. 

Air Brake Tests . --On July 31, 1988, the equivalent of an initial 
terminal air brake test was performed on the 56 cars of Extra 406 East that 



40 

did not derail. Exception was taken to the brake cylinder piston travel on 
6 of the 56 cars tested. 

Representatives from the FRA, the lAIS, and the Safety Board, and the 
chief mechanical officer of the lAIS noted that the lAIS engineer who was 
operating the automatic brake valve during the postaccident air brake test 
was not familiar with the Federal requirements for an initial terminal air 
brake test and was unable to perform the test properly. He had to be 
instructed on various points during the test. During the test of brake pipe 
leakage, the initial reduction was exceeded because the engineer was looking 
at the brake pipe pressure gage instead of the equalizing reservoir pressure 
gage. Also, the observers noted that the engineer was about to cut in the 
brake pipe cut-off valve without reducing the equalizing reservoir to a 
pressure equal to the brake pipe, an action that would have resulted in the 
brakes releasing prior to completion of the test. 

On August 1, 1988, the equivalent of an initial terminal air brake test 
was performed on the four undamaged cars of Extra 470 West. No exception 
was taken to the operation or condition of the brakes on these cars. 

Postaccident Inspection and Pressure Tests of Tank Cars . --On November 1 
and 2, 1988, representatives from the Safety Board, the FRA, the AAR, ADM, 
and ACF Industries, ^^ convened at the rail car repair facility of RESCAR, 
Inc., in Longview, Texas, where both tank cars had been shipped following the 
accident, to inspect the tank cars externally and internally, document any 
damage, assess whether or not hydrostatic tests could be conducted safely 
and, if so, to conduct the hydrostatic tests to determine the general 
integrity of the tank cars and the function of the valves. 

An interior inspection of the tank cars revealed no deficiencies or 
defects. All weld seams and areas of attachments appeared to be in 
excellent condition. The gaskets in the bottom outlet valves were slightly 
off center, but were within normal tolerances. While some creases and areas 
where paint had been burned off were noted during the external inspection, 
there was insufficient damage, such as cracks or spalling, to preclude 
conducting the hydrostatic tests. Before the tests were conducted, gaskets 
made of white neoprene were installed in the manway openings. The ADM 
representative advised that gaskets of white neoprene are used by ADM. The 
safety valves were removed for bench testing and the valve openings were 
sealed for the hydrostatic tests. 

When the hydrostatic tests began and the internal tank pressure slowly 
built toward 100 psig, several small leaks were noted around the safety valve 
mounts and the manway openings on both cars. At this point, the bolts around 
the manway covers were further tightened to the physical ability of the two 
workers involved with the testing. This involved the workers sitting down, 
bracing themselves, and forcing the wrench with their feet. The leaks 
stopped and both cars successfully held 100 psig for over 10 minutes, as 



2 7 

lAIS was invited to participate, but did not send a representative to 

observe the inspection and testing. 



41 

required by Federal regulations. Although the tests were determined to be 
successful, on-scene witnesses expressed concern over the inordinate amount 
of effort expended by the two workers to tighten the bolts and obtain the 
required seal . 

When the pressure relief valves were removed from the tank cars for 
bench testing, the torque required to loosen each of the 8 mounting bolts for 
an individual valve was recorded. (See appendix I.) The B-end valve on 
ADMX 29477 had one loose bolt, and the B-end valve on ADMX 29494 had two 
loose bolts. 

Bench tests were conducted to determine the pressures at which the 
relief valves would open and then reseat. (See appendix I.) The pressure 
relief valves were tested in a vertical position only since the testing 
facilities were not designed for other orientations. Manufacturer's 
specifications stipulate that the valves be fully open at 75 psig, and reseat 
at 60 psig. 

Manwav Gaskets . --The manway gaskets installed in the two tank cars at 
the time of the accident showed evidence of heat damage but no other obvious 
signs of deterioration. The gaskets were submitted to the U.S. Customs 
Laboratory for chemical analysis of the material and surface deposits. The 
results disclosed that the gaskets were composed of a polymer having the 
characteristics of silicon rubber. There was no evidence of any sealants on 
the gaskets. No detectable changes in the properties of the gaskets occurred 
after immersion in a 95 percent ethanol/5 percent gasoline mixture for one 
week. Thermal analysis of the gaskets indicated that the gasket material can 
withstand temperatures of 250 degrees C (480 degrees F) without weight 
loss. 

Other Information 

Disaster Preparedness . --The city of Altoona had an up-to-date disaster 
plan and it was implemented during the accident. Control points around the 
perimeter of the accident site were manned for the duration of the accident 
by the Iowa State Patrol, the Polk County Sheriff's office, and the Altoona 
Police Department. Two churches and an elementary school were opened for 
shelter purposes, and the Salvation Army provided food and beverages 
throughout the incident. 

Polk County had 19 fire departments with 25 rescue units available. 
Polk County also had mutual aid agreements with surrounding counties. It was 
not necessary to exercise these agreements during the accident. 

According to the Altoona fire chief, local emergency response personnel 
had never been contacted by the railroad regarding actions to be taken in the 
event of a hazardous materials incident. 

Shelf Couplers . --In 1982, the National Space Technology Laboratories 
prepared a report, "Analysis of Locomotive Cabs," at the request of the FRA. 
One goal of the report was to "...analyze concepts that are currently 



42 

available for mitigating the car override problem and identify improved 
concepts. ..." 

The report stated: 

When considering the override problem, locomotive coupler 
design is an area of concern. The use of coupler designs, 
such as E or F shelf couplers, would tend to prevent climbing 
at the coupler during a collision. Also, increasing the 
strength of the coupler/draft gear steel to near that of the 
locomotive underframe would tend to decrease climbing during 
impact by containing the collision energy in the couplers and 
undersill areas. 

The report concluded that "One promising candidate concept [in terms of 
override mitigation] that is determined to be technically acceptable and 
economically feasible involves the installation of shelf couplers on 
locomotives." 

Tank Car Fittings . --A 1986 study^s analyzed RSPA's Hazardous Materials 
Information System database. The study attributed the two most frequent 
sources of failure leading to the release of hazardous materials, for the 
rail mode, to defective and loose fittings. Together, these two failure 
modes accounted for 6,567 reported incidents out of a total of 10,465 
incidents reported from 1976 to 1984, or about 63 percent. Individually, 
reports of defective fittings numbered 2,883, or 28 percent of the total. 
Reports of loose fittings numbered 3,684, or 35 percent of the total. Also, 
the study stated that many reportable incidents are not reported and 
therefore not counted in the database. 

Railroad Event Recorders . --Section 10 of the Rail Safety Improvement Act 
of 1988, passed by Congress, directs the Secretary of Transportation to 
"issue such rules, regulations, standards, and orders as may be necessary to 
enhance safety by requiring trains to be equipped with event recorders" 
within a specified time frame. On November 23, 1988, the FRA issued an 
Advanced Notice of Proposed Rulemaking (ANPRM) on railroad event recorders. 
The stated purpose of this ANPRM was to determine "whether Federal regulatory 
intervention is necessary to ensure the presence of event recorders on train 
movements with FRA's jurisdiction, and whether such regulations would be cost 
beneficial." The legislation discussed above was not mentioned in the ANPRM. 

At the FRA's January 10, 1989, public hearing on the issues outlined in 
the ANPRM, the Safety Board made an oral presentation and later submitted 
more detailed written comments in response to the ANPRM. The Board's oral 
presentation stated, in part: 



Transportation of Hazardous Materials . Congress of the United States, 
Office of Technology Assessment, (OTA-SET-304), July 1986, page 84. 



43 

With respect to recorders, the Safety Board's views are shaped by 
years of experience in using recorders to help reconstruct and 

"solve" aircraft accidents The Board's unique perspective with 

the use of voice and data recorders in aviation as accident 
investigation tools have convinced it to call for the use of event 
recorders on trains. 

The Safety Board's recommendation history regarding recorders on 
train movements began on October 6, 1969. As a result of a train 
accident in Laurel, Mississippi, on January 25, 1969, the Safety 
Board issued Safety Recommendation R-69-18 to the FRA. This 
recommendation requested that FRA impose regulations requiring that 
all mainline trains be equipped with speed recorders. Following an 
accident at Glendora, Missouri, on September 11, 1969, the Safety 
Board further recommended, in Safety Recommendation R-70-15 on 
August 19, 1970, that FRA develop and implement instrumentation to 
record train braking performance. The FRA responded with an ANPRM 
on February 4, 1974, which outlined the development of proposed 
regulations to require speed recorders. On November 9, 1977, a 
train accident occurred at Pensacola, Florida, and the Safety Board 
issued Safety Recommendation R-78-44 on July 31, 1978, to the FRA. 
The Safety Board recommended that FRA require event recorders on 
all trains operating on main tracks. On May 21, 1979, the FRA 
finally published the outcome of the deliberations initiated by the 
ANPRM in 1974. The FRA determined that speed recorders were 
neither justified nor, based on the state-of-the-art, feasible. 
The FRA maintained that position in responding to Safety Board 
followup letters in 1980, 1981, and twice in 1985. In fact, in its 
response letter of August 8, 1985, the FRA emphatically stated that 
it intended to give no further consideration to the issue of event 
recorder requirements and requested that the Safety Board close 
Safety Recommendation R-78-44. The Safety Board did close Safety 
Recommendation R-78-44 on November 29, 1985, and placed it in the 
"Unacceptable Action" category. 



If the Rail Safety Improvement Act of 1988 mandates rules requiring 
event recorders, which we believe is the most logical 
interpretation of that statute, the FRA is not free to decide 
whether Federal regulatory intervention on this subject is 
necessary. 

From the outset of the development of the legislation which 
resulted in the inclusion of the provision on event recorders, the 
Congressional proponents of event recorders shared the Safety 
Board's recognition that the information derived from event 
recorders proved invaluable in determining the cause of train 
accidents and preventing more accidents. 

The American Short Line Railroad Association . --The American Short Line 
Railroad Association (ASLRA) was organized in 1917 and by 1918, 177 railroads 



44 

were members. The purpose of the ASLRA is "...to provide cooperative action 
in the consideration and solution of problems of management and policy 
affecting the operation or welfare of shortline railroads, to promote federal 
legislation of benefit, and to resist enactment of legislation that would be 
detrimental to the railroad industry." 

A directory of small railroads published in 1986 contained information 
on 412 shortline railroads. ^9 About 40 percent or 167 of these railroads had 
started operations or had changed owners since 1973. Twenty of these 
railroads, including the lAIS, listed mileage in excess of 100 miles. Since 
1986, several other railroads have started operation from property spun-off 
from Class I carriers (for example, the Montana Rail Link from the Burlington 
Northern, and the Wisconsin Central from the Soo line). According to the 
Official Railway Guide, in 1988 there were 318 regional and shortline 
railroads in operation. The Federal Railroad Administration has oversight 
responsibility for all railroads, including the shortline and regional 
carriers. 



ANALYSIS 



General 



No mechanical defects on the equipment of either train were found that 
would have contributed to the accident. No anomalies or deficiencies in the 
track structure or track geometry were noted that would have contributed to 
the accident. Weather was not a factor in this accident. 

The Accident 

The provisions of train order 213 prohibited Extra 406 East from 
departing Altoona until 12:01 p.m. unless Extra 470 West arrived prior to 
that time. Witness testimony and statements by the crew of Extra 406 East 
indicate that Extra 406 East departed Altoona around 11:40 a.m. and that the 
trains collided about 11:44 a.m., 0.8 mile east of Altoona station. Based on 
the time of the accident and the location of the accident. Extra 470 West had 
more than sufficient time to travel the distance before the expiration of the 
the time designated in the train order. The Board, therefore, concludes that 
the primary causal factor of the accident was the premature departure of the 
traincrew of Extra 406 East from Altoona in violation of the provisions of 
train order 213. Postaccident statements of both the conductor and engineer 
of Extra 406 East indicate that they understood the provisions of train order 
213, but they could not offer any explanation as to why they departed 
Altoona before the designated time of 12:01 p.m. Accordingly, the Safety 
Board's investigation attempted to determine why the crew failed to comply 
with the provisions of train order 213. 

Operation of Extra 406 East . --The Safety Board considered the 
possibility that the crew could have recklessly intended to leave Altoona 
when they did and ignored the dangers and consequences of doing so. No drugs 



29 

American Shortline Railway Guide, 3rd edition, 1986, Edward A, 

Kalnbach Publishing (ISBN 0-89024-073-6). 



Lewis, 



45 

or alcohol were detected in any of the specimens of the engineer or 
conductor of Extra 406 East during postaccident toxicological testing; the 
Safety Board, therefore, rules out the possibility that drugs or alcohol were 
a factor on the crew's decision to depart Altoona before the designated time. 
The crew had set out and picked up cars en route to Altoona and while at 
Altoona, and had complied with the provisions of a meet order with Extra 430 
West while in the CNW yard limits, all apparently without incident. There is 
no evidence to suggest that the crew was operating the train in a reckless 
manner before the accident; therefore, the Safety Board concludes that the 
crew did not deliberately depart Altoona early, cognizant of the dangers and 
consequences of doing so. Consequently, the Safety Board examined various 
factors that may have caused the crew to leave Altoona prematurely. 

When the accident occurred, the crew of Extra 406 East had been on duty 
for just over 10 hours, having reported for work at 1:30 a.m. on the morning 
of the accident. They had worked 10 hours the previous day and were then 
allotted a period of 8 hours of "rest" in accordance with the Hours of 
Service Act. During this period, they checked into a hotel, ate a meal, and 
reportedly received between 4 and 5 hours of sleep before the dispatcher 
called them at 12:30 a.m. to report for work at 1:30 a.m. On Thursday, 
July 28, both crewmembers had been off duty and had experienced a normal 
sleep-wake cycle at home, being awake during daylight hours and sleeping 
during the night. In order to accommodate their work assignment for their 
train movement from Council Bluffs on the day of the accident, the crew 
adjusted their sleep-wake cycle so that they would sleep in preparation for 
the overnight return train movement to Newton. Even though, as previously 
mentioned, the crew performed various work en route to Altoona and while at 
Altoona without incident, it is nevertheless possible that the crew was 
fatigued by the time they reached Altoona. This work could also have placed 
increased demands on the memories of the crew and could have diminished the 
likelihood of their recalling the "wait" provision of the train order. 

The crew of Extra 406 East received a number of train orders during the 
morning hours, the first of which was a meet order (train order 205) with a 
westbound train. Extra 430 West; this order was received and acknowledged by 
the crew of Extra 406 East at 3:37 a.m. Nearly 6 hours later, the crew 
received another train order (211) which instructed the crew that train 
order 205 was annulled and that after Extra 430 West arrived at MP 353.2, 
Extra 406 East could operate from MP 353.2 to Newton. In essence, with the 
issuance of train order 211, Extra 406 East was given authority to operate 
from MP 353.2 to Newton, which included the area through Altoona. About 
2 minutes later, this information was reinforced when Extra 406 East received 
and acknowledged train order 212, which instructed crews of eastbound trains 
between MP 353.2 and Newton, except Extra 406 East, to wait at MP 353.2 until 
2 p.m. Approximately 20 minutes later. Extra 406 East received train order 
213, which again instructed the crew that it could operate from MP 353.2 to 
Newton but that now it would have to wait at Altoona until 12:01 p.m. for 
Extra 470 West, Although the engineer stated that he heard and understood 
the train order when the conductor copied the order, there was no further 
discussion between the crewmembers concerning the order. Nearly 2 hours 
elapsed from the time the traincrew received train order 213 and the time 
the crew departed Altoona. Had the crew been prudent and acted in accordance 



46 

with operating rules, they would have reviewed and verified with each other 
the train orders received before departing Altoona. 

The Safety Board is concerned with the dispatcher's issuance of train 
order 213 to Extra 406 East in terms of the wording and the contents of the 
train order. Prior to issuing train order 213, the dispatcher had issued two 
other train orders to Extra 406 East that gave the train authority to operate 
to Newton. The wording of the first part of train order 213 (Extra 406 East 
has right over Extra 470 West MP 353.2 to Newton) would indicate to the crews 
that they have the authority to operate between those points. However, the 
wording of the last part of the train order (and wait at Altoona until 1201 
for Extra 470 West) stipulates a condition which, in essence, nullifies the 
authority of Extra 406 East to operate beyond Altoona until 1201 or the 
arrival of Extra 470 West, whichever occurs first. The Safety Board is 
concerned that train order 213, in conjunction with the two previously issued 
train orders, may have further developed a "mind set" on the part of the crew 
of Extra 406 East that they were cleared to operate to Newton. Moreover, the 
Safety Board is concerned that Extra 406 East was granted authority to 
operate in an area where there was an opposing train movement. The Safety 
Board believes that this accident could have been prevented by a modification 
of the train order or if a type of track warrant system had been in place. 
In either case. Extra 406 East should then have been given authority to 
operate only as far as Altoona. Once the crew reached Altoona, they would 
have then been required to contact the dispatcher and obtain permission to 
proceed east of Altoona. 

The engineer and conductor of Extra 406 East both expressed concern 
about exceeding the 12-hour duty time limit although the crew should have 
had sufficient time to travel the approximately 24 1/2 miles from Altoona to 
Newton before 1:30 p.m., the time when their 12 hours would have expired. 
Furthermore, the engineer was on his second train movement since being 
promoted to engineer and had never operated a train of the weight and length 
of Extra 406 East. Given that he had operated this train without incident to 
Altoona and given the crewmembers' statements expressing concern about the 
12-hour, on-duty limit, it is possible that the crew was preoccupied with 
reaching Newton and finishing their first tour of duty with the engineer 
operating the train. 

The crew of Extra 406 East made no attempt to radio the dispatcher or 
the crew of Extra 470 West to determine the whereabouts of that train and 
apparently was not concerned with the location of the train. After receiving 
a number of train orders in the early morning hours and then passing an lAIS 
train in the CNW yard, the crew of Extra 406 East might have believed that 
they had passed Extra 470 West, when indeed it was Extra 430 West, and that 
they had a clear track to Newton. 

While there is a lack of sufficient evidence for the Safety Board to 
conclude positively why the crew departed Altoona without regard to the 
provisions of train order 213, the Safety Board believes that a combination 
of fatigue, preoccupation with completing their assignment, and the work 
activities that intervened between the time the crew received the train order 



47 

and departed Altoona, were factors that caused the crew to forget the "wait" 
provision of train order 213. 

The engineer stated that he moved the throttle as far as the fifth 
position when operating the train leaving Altoona, and that the train was 
traveling between 15 and 20 mph when he observed Extra 470 West approaching 
at a distance he estimated to be about 300 feet. The exact speed of the 
train could not be determined because lAIS does not equip its locomotive 
units with event recorders. However, since the accident occurred within yard 
limits, Extra 406 East should have been traveling at restricted speed, a 
speed which would have permitted the crew to stop the train within 1/2 the 
range of vision, short of an approaching train. As of the date of the 
accident, yard limit signs had not been installed and the yard limits were 
not listed in the timetable, train orders, or special instructions. The 
engineer stated that he was aware that yard limits had been established at 
Altoona, but that he did not know how far they extended. Postaccident 
observation of the automatic brake valve in the "emergency" position 
indicated that the engineer did apply the train brakes with an emergency 
application before exiting the cab. Postaccident sight distance tests 
indicated that the greatest distance at which the crews of the two trains 
could have seen each other was 1,016 feet. However, since the foliage and 
the embankments were extensively altered when the wreckage was cleared, the 
Safety Board cannot consider the results of the sight distance tests as 
conclusive. Therefore, the Board was unable to determine the precise 
distance at which Extra 406 East would have been able to see Extra 470 West. 

Operation of Extra 470 West . --Because neither crewmember of Extra 470 
West survived the accident and since the lAIS did not equip its locomotive 
units with event recorders, the Safety Board was unable to determine the 
speed of the train at the time of the accident. 

The assistant superintendent of operations, who was performing the 
duties of a train order operator in Newton on the day of the accident, stated 
that he saw one of the crewmembers of Extra 470 West pick up the orders that 
had been placed on a desk in that office. However, since he did not discuss 
the train orders with the crewmember, he had no way of knowing if the 
crewmember fully understood the train orders or if the crew discussed the 
orders before departing Newton. 

By Rule S-87, Extra 470 West had until 11:56 a.m. to reach Altoona 
before Extra 406 East was to depart that location. If the traincrew of Extra 
470 West did receive and understand train order 213, they had no reason to 
expect to encounter Extra 406 East before arriving at Altoona. Based on the 
time of the accident and the location of the accident, as previously noted. 
Extra 470 West had more than sufficient time to travel the distance to 
Altoona before Extra 406 was to depart. Had the crew of Extra 470 West been 
delayed en route to Altoona and not been able to reach Altoona before 11:56 
a.m., they would have been required by Rule S-87 to be clear of the main 



48 

track by 11:56 a.m., either at Colfax or Mitchelvil1e,3° and Extra 406 East, 
departing at 12:01 p.m., could expect the main track to be clear to Newton. 

Since the accident occurred within yard limit territory. Extra 470 West 
should have been traveling at restricted speed. Since yard limit signs had 
not been installed before the accident and given the testimony of the 
engineer of Extra 406 East that indicated he did not know how far the yard 
limits at Altoona extended, it is reasonable to assume that the crew of Extra 
470 West may also have been unaware of the yard limits and had not yet 
reduced speed from the authorized track speed of 25 mph. 

Postaccident testing and inspection of the A-1 charging cut-off pilot 
valve from the locomotive unit of Extra 470 West indicated that the valve was 
functioning as designed and that Extra 470 West experienced an emergency 
application of the train line air brakes as a result of a "break-in-two," or 
train line separation, and not as a result of an emergency application by the 
head-end crew. This evidence could suggest that the engineer of Extra 470 
West was unaware of the impending collision or had too little notice to place 
his train's brakes in emergency. It is also possible, however, that the crew 
may have made a service application of the brakes to reduce speed to 
restricted speed, an act which could have been verified had event recorders 
been used on lAIS locomotives. In summary, there is insufficient evidence 
for the Safety Board to make any definitive conclusions regarding the 
operation of Extra 470 West prior to the collision other than the crew had 
sufficient time to reach Altoona before the designated time and were not 
expecting to encounter a train before reaching that location, and the crew 
did not place the train's brakes into emergency. 

lAIS Method of Operation and Management Oversight 

While paramount in this accident was the failure of the traincrew of 
Extra 406 East to comply with the "wait" provision of a train order, the 
Safety Board's investigation revealed numerous violations of the company's 
operating rules and provisions of the Federal regulations and deficiencies in 
the lAIS method of operations. Accordingly, the Board attempted to determine 
how these violations affected the safe operation of trains on the lAIS and 
what factor they might have played in the cause of this accident. 

Failure to Resolve Status of Signal System . --The lAIS was operating 
trains over nonsignaled territory between Newton and Des Moines, Iowa, and 
according to the FRA had authority to do so for the area where the accident 
occurred; however, the lAIS was never formally informed of this by the FRA. 
Furthermore, communication from the FRA regarding the previously granted 
approvals to the CNW and the Iowa Railroad was not accurate. Before the lAIS 
began operations in 1984, it requested that the FRA extend to the lAIS all 
previously granted relief to operate without the signal system. The FRA's 
letter in response to this request indicated that the relief extended to the 
Iowa Railroad had expired on November 18, 1984. If the lAIS believed that 



^^ lAIS Timetable No. 2 shows other track at these locations and a 
siding at Colfax. 



49 

they had permanent authority, the FRA's letter discussing temporary reliefs 
should have raised some concerns on the part of the IMS. The lAIS claimed, 
however, that it had made a request to the FRA to operate permanently without 
use of the block signal system on April 14, 1987, nearly 2 1/2 years later, 
but did not receive a reply. The FRA Standards Division Chief for Signals 
stated to the Safety Board that the FRA had not received this request. The 
Safety Board believes that since the temporary relief had expired on November 
18, 1984, the FRA and the lAIS should have resolved the block signal 
applications before the lAIS was authorized to begin operations. The Safety 
Board believes that the lAIS knew or should have known that the temporary 
relief to operate trains without use of a signal system had expired and it 
should not have waited nearly 2 1/2 years before asking the FRA, as the lAIS 
claims it did, to permit the permanent operation without use of a signal 
system. 

Failure to Verify Train Orders Issued . --When trains are being operated 
over nonsignaled (dark) territory, the need for up-to-date timetables, 
special instructions, specific procedures for issuing and verifying train 
orders, as well as compliance with train orders becomes critical to the safe 
operation of trains. The assistant superintendent of operations, who was 
serving as a train order operator in Newton on the day of the accident, 
testified that he received and copied the train orders for Extra 470 West 
from the dispatcher in Iowa City, placed them on a desk in the office, and 
observed a crewmember pick up the train orders. Because the lAIS had no 
operating rules or procedures in place that required the train order operator 
to verify to the dispatcher that train orders have been received by the 
traincrews, on the day of the accident the dispatcher had no way of knowing 
if the crew of Extra 470 West had received their train orders. 

The Safety Board has previously addressed the problem of train orders 
being issued but not verified. In its investigation of the head-on collision 
of CSX Transportation freight trains Extra 4443 North and Extra 4309 South at 
East Concord, New York, on February 6, 1987,^^ the Safety Board found that 
"CSX management failed to issue and enforce specific procedures for 

traincrews to verify the accuracy of train orders before departing " The 

dispatcher involved in that accident was issuing train orders via telecopier 
to an unmanned location and, consequently, had no way of knowing if 
traincrews were receiving updated orders. 

The Safety Board believes that the accident at Altoona again illustrates 
the shortcomings of not having a procedure in place for dispatchers to verify 
that train orders have been received and understood by the traincrews. 
Accordingly, the Safety Board believes that the lAIS should develop and 
enforce the use of a procedure that will require the train order operator to 
verify to the dispatcher that train orders issued have been received by 
traincrews. 



'^ Railroad Accident R epo r t - - " H ead - On Collision of CSX Transportation 
Freight Trains Extra 4443 North and Extra 4309 South, East Concord, New York, 
February 6, 1987" ( NTSB/RAR - 88/03 ) . 



50 

Failure to Maintain a Record of Train Movements . --Not only could the 
dispatcher not be assured that the traincrew of Extra 470 West received their 
train orders, on the day of the accident he had no way of knowing when or if 
Extra 470 West had departed its initial terminal. The traincrew did not 
report its departure from Newton, and there were no departure times recorded 
on the train sheets for Extra 470 West on July 30, 1988. According to 
testimony, the arrival and departure times of trains were reported only if an 
agent or "someone" at a station took the initiative to do so or if the crew 
remembered to call the dispatcher. By Federal regulations, dispatchers are 
required to maintain a record of train movements including the direction of 
movement and the time each train passes all reporting stations, and the 
arrival and departure times of trains at all reporting stations. Newton was 
designated by the lAIS as a reporting station. 

The Safety Board is concerned about the ability of a train dispatcher to 
move trains safely over his territory if he is unaware of the whereabouts of 
the trains. Accordingly, the Safety Board believes that the lAIS should take 
immediate action to require that train dispatchers maintain an accurate 
record of train movements, in accordance with Federal regulations. 

Failure to Install Yard Limit Signs . --By general order No. 2, dated 
January 1, 1988, the lAIS had established the Altoona yard limits from 
MP 346.0 to MP 347.5 and had designated the yard limit signs to be installed 
by a general order, dated July 8, 1988. Federal regulations require that 
yard limits be designated by yard limit signs and listed in timetable, train 
orders, or special instructions. However, the investigation revealed that 
yard limit signs had not been installed and that the yard limits for Altoona 
were not shown in the timetable or in the special instructions and were not 
listed on train orders. Therefore, the general order was the only means by 
which traincrews could have been aware of the yard limits at Altoona. 
Testimony from the engineer of Extra 406 East indicated that he was aware 
that yard limits existed at Altoona, but he was not certain how far the yard 
limits extended. While the Safety Board believes that traincrews should 
certainly be aware and familiar with general orders, the on-board documents 
to which traincrews readily refer are timetables, special instructions and 
train orders, and these documents should reflect the most up-to-date 
information pertaining to train operations. 

The speed of Extra 470 West at the time of the accident could not be 
determined. As previously noted, however, it is not unreasonable to assume 
that, as was the crew of Extra 406 East, the crew of Extra 470 West may not 
have been aware of the yard limits at Altoona. Had a "Yard Limit Approach" 
sign been installed 1 mile east of where the yard limits began on the east 
side of Altoona, the sign might have alerted the crew to be prepared to 
reduce speed to restricted speed. Based on the definition of restricted 
speed, had both trains been operated at restricted speed, the accident should 
have been avoided. Nevertheless, the Safety Board believes that if 
traincrews are expected to operate trains within yard limits in accordance 
with certain operating rules, it is reasonable to expect management to 
provide the traincrews with all the necessary information to do so. The 
Safety Board further believes that the management of lAIS should not have 



51 

issued the general order establishing yard limits until it was prepared to 
install the appropriate signs. 

Failure to Provide Instructions on Air Brake Tests . --Although company 
rules and Federal regulations require that when a train is originally made up 
and when a train consist is changed en route a test of the train air brake 
system must be conducted, the investigation revealed that the air brake tests 
were not being conducted on a regular basis. Testimony of the crew of Extra 
406 East indicated that an air brake test was not performed at any of the 
locations where cars were set out or picked up en route from Council Bluffs 
to Altoona. The lAIS engineer who was operating the automatic brake valve 
during the postaccident air brake test was not familiar with the Federal 
requirements and was unable to perform the test properly. The Safety Board 
is concerned that not only were air brake tests not being conducted in 
accordance with company rules and Federal regulations, but that management 
did not provide any guidance or instructions for conducting air brake tests 
with an end-of-train device in cabooseless operations. Although the lAIS had 
adopted the "Rules and Instructions for Train Handling and Operation of Air 
Brakes," which had been in effect on the former Rock Island since 1974, 
management made no effort to determine that all traincrews had copies of the 
manual. More importantly, however, the lAIS operates cabooseless trains with 
an end-of-train device, and management did not update the manual which 
contains no instructions for conducting air brake tests with an end-of-train 
device in cabooseless operations. 

Failure to Provide Adequate Training on the Operating Rules . --The lAIS 
began operations in November 1984. In April 1987, the railroad adopted the 
General Code of Operating Rules as its book of rules. During the interim 
period, the railroad operated under the Uniform Code of Operating Rules that 
had been used on the former Rock Island. Testimony of lAIS officials 
indicated that operating employees, by virtue of their previous experience 
with the Rock Island, were considered qualified for the positions for which 
they were hired on the lAIS. Employees were given no training when the lAIS 
began operations in 1984 or during the interim period before the railroad 
adopted the General Code of Operating Rules. The company apparently believed 
that these employees were sufficiently competent and that training was not 
needed. The Safety Board believes that lAIS management was remiss in not 
providing recurrent training on the operating rules for the more than 2 years 
that the railroad operated under the Uniform Code of Operating Rules. 

lAIS records indicate that after adopting the General Code of Operating 
Rules in April 1987, the railroad provided classroom instruction on the rules 
to 70 percent of its operating employees. The crew of Extra 406 East and the 
engineer of Extra 470 West had attended this classroom instruction. The 
conductor of Extra 470 West, who was hired by the lAIS several months later, 
did not attend the training or receive any formal rules training following 
his employment. Likewise, 30 percent of the operating employees on the lAIS 
had not received training on the General Code of Operating Rules. 

The superintendent of operations and other railroad officials conducted 
the training classes in 1987 and indicated that an "oral examination" was 
given to employees following each class. When asked to describe how the oral 



52 

examinations were administered, the superintendent of operations stated that 
questions were randomly chosen and posed to the class as a whole and were 
discussed by the group. A written examination was not administered, and no 
other method was used to measure an individual employee's knowledge and 
understanding of the operating rules. Since the training provided by the 
railroad failed to require each employee to demonstrate an adequate knowledge 
of the operating rules, management could not be assured that operating 
employees could satisfactorily and safely perform train movements. lAIS 
management was apparently willing to accept this risk, even though it was 
operating a "dark railroad" which relied solely on compliance with train 
orders and operating rules. The Safety Board concludes that the operating 
rules training program used on the lAIS was ineffective and failed to 
determine that operating employees were sufficiently knowledgeable of the 
operating rules. 

Failure to Provide Effective Training for Engineer Trainees . --The lAIS 
had adopted a training program used by a predecessor railroad for the 
promotion of operating employees to the position of locomotive engineer. 
While the Safety Board's investigation indicated that in general the program 
was well conceived, management failed to implement fully the program as 
outlined and failed to provide the framework necessary for an effective 
training program. 

Student engineers were afforded the opportunity to experience the hands- 
on aspects of locomotive operations during the three phases of the program 
which were to be completed in a 6-month timeframe. This opportunity was 
limited, however, because the trainee was responsible for performing the 
duties of the conductor, and at times this required the trainee to be on the 
ground and away from the locomotive. The investigation revealed that the 
engineer of Extra 406 East had few opportunities to experience over-the-road 
training because he was assigned to the Newton yard during most of his 
training period performing switching movements. Furthermore, the Safety 
Board believes that a student engineer cannot receive adequate instruction on 
the full-time duties of an engineer while at the same time performing the 
full-time duties of a conductor. 

Further, the railroad did not determine if the training was effective 
or adequate because it did not monitor the progress of student engineers or 
evaluate their performance during training. Although required by the 
program, engineer instructors did not submit timely progress reports, 
observations, and comments in written form. The assistant superintendent of 
operations, the immediate supervisor of the engineer of Extra 406 East, 
failed to evaluate the engineer during each phase of his training and did not 
certify that he was qualified for the position of engineer upon completion of 
training, as outlined in the program. Testimony indicated that the assistant 
superintendent of operations, who, according to the program, was required to 
evaluate the performance of student engineers and certify that they were 
qualified to function as a locomotive engineer, had never been qualified as a 
locomotive engineer. The Safety Board is concerned that an individual who 
has never performed the duties of an engineer may not be capable of 
adequately evaluating the performance of a trainee for that position. 



53 

The superintendent of operations stated that any engineer on the IMS 
roster could serve as an instructor and be assigned to train a student 
engineer. Testimony from engineers who had served as instructors indicated, 
however, that they had not read the manual which outlined the training 
program and had not been given any guidance or instruction on the material 
that should be covered during the various phases of training. The Safety 
Board is concerned about the quality of training that trainees could receive 
when instructors were not provided any guidance by management and were not 
evaluating the performance of the trainees assigned to them. Moreover, the 
Safety Board believes that there is an inherent conflict in having the 
trainee perform the duties of conductor, who according to the operating rules 
is in charge of the train, and at the same time be instructed on the duties 
of engineer. 

The engineer of Extra 406 East was on his first trip and second train 
movement following his promotion to engineer 5 days earlier. The engineer 
had been trained primarily in yard switching operations and had not 
previously handled a train of the tonnage and length of Extra 406 East. The 
Safety Board believes that training must be conducted in a way in which 
employees can demonstrate their ability to operate trains over the territory 
in which they will be operating and with the type of trains they will be 
expected to handle. 

In summary, the Board believes that the training program instituted by 
the lAIS to promote individuals to the position of engineer was deficient 
because (1) the trainee's exposure to and observation of locomotive 
operations during the three phases of OJT was unacceptably limited because he 
was required to perform the duties of conductor during this time; (2) 
management failed to evaluate the performance of the trainees to assess their 
knowledge of operating rules and ability to handle a locomotive; and (3) 
management failed to provide adequate instructions and guidance to the 
engineer instructors on the material to be covered during the phases of OJT. 

Failure to Qualify Crews on Operating Rules of Other Railroads . --The 
Safety Board received conflicting testimony regarding whether lAIS 
traincrews had been qualified on the Chicago North Western (CNW) operating 
rules to operate over trackage of the CNW at Des Moines. The superintendent 
of operations of the lAIS stated that crews had been qualified on the CNW 
rules. However, the engineer of Extra 406 East stated that he had not been 
qualified on the CNW rules. The Safety Board requested but did not receive 
from the lAIS a list of employees qualified on the CNW and the method by 
which the employees were qualified. The investigation revealed that lAIS 
also operates over trackage of METRA and the CSX. The Safety Board believes 
that the lAIS should require its operating employees to be properly qualified 
on the operating rules for the territory of the other railroads over which 
they operate before they are allowed to operate as the engineer and 
conductor. Furthermore, the CNW, the CSX, and METRA are responsible for 
determining if crews of other railroads operating over their territory are 
qualified on the respective company rules. The Safety Board believes that 
these railroads should determine if lAIS crews operating over their territory 
are properly qualified. 



54 

The lAIS operates over trackage of the Des Moines Union and the Chicago 
North Western Transportation Company (CNW) between MP 353.2 and MP 364.5. 
Newton is the initial station of crews operating over this territory. 
According to the lAIS operating rules, general orders, bulletins, notices 
and circulars will be posted in books and/or on bulletin boards at stations 
designated in the timetable. lAIS timetable No. 2 designated Newton as a 
station where general order boards or books were located. The investigation 
revealed, however, that current general orders, general notices, and special 
instructions of the CNW were not posted on the bulletin board at Newton. 

Failure to Conduct Operational Tests and Inspections . --The Safety 
Board's investigation found little evidence that lAIS supervisors monitored 
crew compliance with operating rules, even though the ratio of supervisors to 
employees suggests that each supervisor would not be charged with overseeing 
a large group of employees. In fact, operational efficiency checking was not 
performed. lAIS officials cited various reasons for not performing 
operational tests and inspections including that the company had waivers from 
the FRA permitting the lAIS to not perform operational tests. The lAIS, 
however, could not provide documentation for an exemption or waiver. The 
assistant superintendent of operations stated that he did not perform 
efficiency testing "on orders from the superintendent of operations." 
Testimony from operating employees indicated that there was very little 
supervision of the day-to-day operations of trains and enginecrews outside 
the terminals and that supervisors rarely rode trains. When operating 
personnel believe that they will rarely encounter supervisors and that 
management is not concerned with strict adherence to operating rules, a 
diminishment of inducements for operating personnel to comply with these 
rules can occur. By not filling the position of road foreman of engines, a 
position that has responsibility for overseeing the enginecrews, management 
indicated to operating personnel that it was not overly concerned with the 
oversight of day-to-day operations. 

According to the personnel records of the employees involved in this 
accident, only the chief dispatcher and conductor of Extra 406 East had a 
prior record of disciplinary action while employed with the lAIS. Both 
employees had been given letters of reprimand, and according to the 
superintendent of operations, the lAIS policy regarding disciplinary action 
was that three letters of reprimand could constitute grounds for dismissal. 
The conductor was issued a letter of reprimand for violation of a train 
order--leaving a waiting point before the designated time. This letter of 
reprimand apparently, however, had little effect on the conductor's adherence 
to operating rules, specifically compliance with train orders. If management 
is lax in consistently citing rules violations with appropriate disciplinary 
action, there is no incentive for employees to adhere to operating rules. 

Failure to Properly Abandon Signal System . --During the investigation of 
this accident, it was noted that signal No. 3472, located 0.3 mile west of 
the Altoona station sign, had not been removed, covered, or turned away from 
the track. When an out-of-service signal is left in place, the common 
industry practice (there is no Federal guidance on this issue) is to cover 
the signal head or turn the signal away from the track that it would govern. 
Signal No. 3472, although inoperable, displayed a dark aspect, which, 



55 

according to the operating rules, should be interpreted by the crew as its 
most restrictive signal indication requiring the train to stop. The failure 
to have this signal covered or turned away from the track was not corrected 
by lAIS officials even though the deficiency should have been detected during 
operating inspections. Further, the deficiency apparently was not raised 
with the lAIS by the FRA, although it too should have performed inspections 
that should have revealed the deficiency. Either these inspections were not 
performed or the lAIS and the FRA considered it an acceptable situation. 

In summary, the Safety Board believes that the failure of lAIS 
management to comply with its own rules and Federal regulations, to oversee 
its train operations and enforce compliance with operating rules, and to 
adequately train and qualify its operating personnel fostered an atmosphere 
of complacency by operating personnel toward compliance with operating rules 
and this contributed to the cause of the accident. 

Lack of Cooperation by lAIS in Safety Board's Investigation . --The Safety 
Board is concerned with the lack of cooperation demonstrated by the lAIS 
during this accident investigation, particularly since the railroad was made 
a party to the Safety Board's investigation and deposition proceedings. Four 
lAIS officers required a federal court order before they would present 
testimony at the Safety Board's deposition proceedings held on October 18, 
19, and 21, 1988, at Des Moines, Iowa. At the close of the deposition 
proceedings, all parties were invited to submit to the Safety Board their 
proposed findings and conclusions regarding the accident. The Safety Board 
did not receive any submissions from any of the parties, including the lAIS. 
During the course of the investigation, the Safety Board requested additional 
information from the lAIS that the Board believed was vital to the 
investigation. The lAIS did not provide all the information requested. On 
March 29, 1989, a technical review of the Safety Board's factual report of 
the accident was conducted at Cedar Rapids, Iowa, approximately 10 miles from 
the railroad's headquarters. All parties to the investigation were invited 
to present comments either in writing or by attending the meeting. The lAIS 
did not attend or respond. The Safety Board met on May 9, 1989, in 
Washington, D.C. to consider the full report and determine the probable cause 
of the accident. Although informed 2 weeks prior to the date of the meeting, 
the lAIS did not attend. The Safety Board does not believe that the attitude 
reflected in the aformentioned actions of the lAIS promotes transportation 
safety and, in fact, could be interpreted as indicative of management's 
approach to the safety of train operations. 

Federal Activity 

Federal Oversight of IAIS .--The lAIS was operating a "dark" 
(nonsignaled) territory, and apparently had authority to do so for the area 
in which the accident occurred, but had never been formally informed of this 
by the FRA. While the FRA has a process in place for granting authority to 
discontinue the use of signal systems and was implemented with the CNW and 
the Iowa Railroad, there were deficiencies in the FRA's communication with 
the lAIS that did not reflect the status of authorities previously granted. 
After granting authority to the lAIS to operate without use of the signal 
system only on a temporary basis, the FRA failed to follow up with the lAIS 



56 

to determine the status of the lAIS' request regarding use of the signal 
system. On-site inspection of lAIS operations by FRA personnel should have 
indicated readily that the lAIS was not operating with a signal system. The 
Safety Board believes that the FRA should reevaluate and resolve the status 
of block signal applications for the lAIS based on the current operations 
which now include two daily through trains, several local trains, consists 
which include hazardous materials, and the operation of passenger 
excursions. 

The provisions of 49 CFR Part 217 outline the FRA's requirements for 
railroads (1) to file a copy of its operating rules, timetables, and special 
instructions, (2) to file a program for conducting operational tests and 
inspections to determine compliance with operating rules, and (3) to file a 
program of instruction on operating rules. Based on information received 
during a meeting with FRA personnel on September 7, 1988, and in a letter 
dated January 18, 1989, the lAIS was not in compliance with the provisions of 
49 CFR 217 and had not been granted an exemption or waiver from these 
provisions. On September 2, 1987, at Blue Island, Illinois, an FRA inspector 
had noted a defect on an inspection report with regard to 49 CFR 217.9 and 
that he found, through discussion with company officials, that the lAIS did 
not periodically conduct operational tests and inspections to determine 
compliance with its operating rules, timetables and special instructions. 
There was no fine imposed or violation reported at that time, and apparently 
there was a lack of understanding between FRA and field personnel as to the 
action to be taken after a defect has been noted on an inspection report. In 
response to the Safety Board's request as to how this defect was resolved, 
the FRA, in its January 18, 1989, letter indicated that carrier officials had 
been admonished to bring the lAIS programs into compliance with the 
provisions of 49 CFR Part 217. 

Although FRA inspectors noted defects on inspection reports in October 
1986 that rule books were not available and in September 1987 that the lAIS 
did not conduct operational tests or inspections, there is no record that the 
FRA noted any defects on inspection reports that the lAIS failed to install 
yard limit signs, even though Federal regulations require that yard limit 
signs be installed and that yard limits be designated in the timetable, train 
orders, and special instructions. The FRA informed the Safety Board in its 
January 18, 1989, letter that it has now initiated an enforcement action 
against the lAIS for violation of Federal regulations pertaining to operating 
rules. Nothwithstanding this enforcement action, the Safety Board concludes 
that for more than 3 years the FRA failed to exercise its statutory 
responsibility to oversee adequately railroad operations on the lAIS. 

Because of the Safety Board's concern about the FRA's lack of oversight 
of lAIS operations, the Safety Board believes that the FRA should take 
immediate action to conduct a safety audit of the operating practices of the 
lAIS. 

The Safety Board is also concerned that the FRA does not have a system 
in place to determine that defects noted on field inspection reports have 
been followed up by FRA inspectors to verify that corrective action has been 
taken by the carrier. Furthermore, while defects noted on inspection reports 



57 

are entered into a computer data base, there is no formal process for the 
systematic evaluation of this data base. Given the FRA's reliance on its 
field personnel to notice trends in a carrier's operations but the lack of 
communication and coordination between field and headquarters personnel, the 
Safety Board is concerned that a carrier's noncompliance with Federal 
regulations is not receiving the attention it needs from top FRA officials. 
Accordingly, the Safety Board urges the FRA to take immediate action to 
implement a program that will (1) provide consistent followup of defects 
noted on inspection reports to verify that corrective action has been taken, 
(2) outline in detail the responsibilities of field and headquarters 
personnel regarding defects and violations noted, and (3) alert FRA officials 
of a carrier's noncompliance with Federal regulations and of trends in 
carriers' operations. 

Accident Reporting Criteria . --In addition to the accident at Altoona, on 
July 30, 1988, four other rail equipment accidents in which damages exceeded 
$150,000 have occurred on the lAIS since it began operations. One of the 
accidents involved the release of hazardous materials. Although each of the 
four accidents met the Safety Board's accident notification criteria, the 
Board was not notified of any of the accidents. The chief operating officer 
of the lAIS stated that he was not aware of the Safety Board's accident 
notification criteria. Testimony of the chief dispatcher indicated there 
were no written procedures or list of numbers to call in the event of any 
emergency. Although required by Federal regulations, the carrier failed to 
report the two accidents that involved the release of hazardous materials to 
RSPA of the U.S. DOT. The lAIS did file a report with the FRA for each of 
the five accidents, and, according to the chief operating officer, the 
company official responsible for reporting to the FRA would also be 
responsible for reporting any hazardous materials reports. 

The foregoing suggests that the senior management of the lAIS was not 
familiar with all Federal reporting requirements and, consequently, provided 
no guidance or written procedures on the reporting of accidents on the lAIS 
property. Although the chief dispatcher stated that he now has prepared "a 
list of numbers to call," as a result of the Safety Board's investigation, 
the Safety Board remains concerned that lAIS management has not provided 
adequate guidance in this area. The Safety Board believes that lAIS should 
develop explicit written procedures concerning the Federal agencies to be 
contacted in the event of a railroad accident on the lAIS. The Safety Board 
is further concerned that this situation may exist on other regional 
railroads and that accidents, including those involving the release of 
hazardous materials, may not be reported in accordance with Federal 
regulations. While the Safety Board recognizes that it is the responsibility 
of railroad management to know the requirements of Federal regulations, the 
Safety Board believes that the American Short Line Railroad Association could 
address this issue by disseminating information to its membership regarding 
Federal agencies' accident notification criteria. 

Although RSPA has received hazardous materials incident reports filed by 
various carriers in which tank cars shipped by ADM's Cedar Rapids plant have 
released hazardous materials, ADM's plant manager at Cedar Rapids stated that 
he had not received any formal notification from carriers regarding problems 



58 

with tank cars loaded at his facility. The investigation of this accident 
revealed that lAIS had not planned to contact the shipper of the hazardous 
materials until urged to do so by a Safety Board investigator. The shipper 
has the responsibility under Federal regulations to properly prepare the 
hazardous materials for transportation. The Safety Board is concerned, 
however, that without specific direction, a carrier is not obligated to 
contact a shipper if a problem occurs during transportation with the 
shipper's tank car or other type of container. If shippers are unaware of 
problems involving their containers during shipment, they cannot be expected 
to take corrective action. Shippers could be easily notified of hazardous 
materials incidents involving their containers if the carriers provided the 
shippers with a copy of the Hazardous Materials Incident Report that carriers 
are now required to submit to RSPA. The Safety Board believes that such 
action would make shippers aware of problems, and urges RSPA to amend 
49 CFR 71.16 to require carriers to provide the shippers with a copy of the 
written incident report submitted to RSPA. 

Transportation of Hazardous Materials 

Safety Board investigators examined closely the tank cars involved in 
this accident. The Safety Board found that the tank cars involved in this 
accident had minimal structural damage, as documented during the postaccident 
inspections and testing; yet, product was released through their fittings 
even before being exposed to heat or fire. The Board believes that, based on 
the minimal damage to the tank cars, they should not have leaked and released 
the denatured alcohol. 

The leaking and burning tank cars, while not a factor in the cause of 
the accident, increased the danger and severity of the accident, prompting 
local emergency response personnel to evacuate nearby residents. Also, 
recovery of the two fatalities and wreckage removal was made more hazardous 
by the burning tank cars, and the emergency response personnel were 
confronted with a higher degree of danger. 

Release and Ignition of Denatured Alcohol .--The descriptions by the two 
police officers who climbed on top of the overturned ADMX 29477 indicate that 
at least one pressure relief valve was leaking alcohol before the grass fire 
reached the tank car. It is unknown, however, whether the initial leakage 
occurred through the valve itself or at the bolted flange connection of the 
pressure relief valve assembly and the support flange on the tank car. 
Although the two police officers only observed the one pressure relief valve 
leaking before the tank cars caught fire, it is likely that more than one of 
the pressure relief valves were leaking. The observations of the 
firefighters, the hazardous materials team members and the AAR field 
inspector on the afternoon and evening of the accident indicate that both 
tank cars were burning at the pressure relief valves. Further, the pressure 
relief valve on the A-end of ADMX 29494, which during the bench tests opened 
and reseated nearly at the manufacturer's specifications, was observed by a 
Safety Board investigator to be leaking through the valve on August 2. 

Although the police officers did not observe the manway on either car to 
be leaking, both manways likely were leaking after the accident. Photographs 



59 

of the two tank cars while they were burning and the scorched and burned 
areas found on the two tank cars after the fires were out indicate that the 
fires were fueled by alcohol leaking from the manway on each car. 

The grass fire that started from the burning locomotives progressed to 
the tank cars and ignited the leaking alcohol from the manway and pressure 
relief valves. Aerial photographs clearly indicate a blackened area of 
ground extending from the area of the locomotives back toward the two tank 
cars. The fire, upon reaching the two tank cars, ignited the alcohol leaking 
from the manways and the pressure relief valves. With the exception of the 
pressure relief valve on the B-end of ADMX 29494, all of the pressure relief 
valves and the manway showed evidence of heat damage, which further 
compromised the integrity of these closures. 

Mode of Release . --Since the tank cars were leaking before they were 
exposed to any fire, and since the pressure relief valves and the manway on 
each car had no external impact damage, these fittings were either subjected 
to excessive internal forces generated during the derailment, or these 
fittings were not properly secured when the tank cars were released from the 
shipper. 

When the accident occurred, ADMX 29477 was loaded with 29,104 gallons or 
to 95.6 percent of capacity, and ADMX 29494 was loaded with 29,105 gallons or 
to 96.5 percent of capacity. After the tank cars overturned but before they 
caught fire, the manways and the pressure relief valves were subjected to 
dynamic and static internal forces from the liquid and vapor in the tank. 
Calculations indicate that the static pressure on the manways and the 
pressure relief valves would have been about 5.6 psig, assuming that the 
temperature in each tank was 120 degrees F, at the time of the accident. 
Since the air temperature was about 90 degrees F when the accident occurred, 
internal tank temperatures were probably the same or slightly higher than the 
ambient air temperature. Therefore, it is likely that the actual static 
internal tank pressure would have been less than the calculated value of 
5.6 psig. Thus, the calculated tank pressure provides a reasonable upper 
limit of the static internal pressure in each tank. Since the pressure 
relief valves were rated to open at 75 psig, the static pressure in either 
tank car was far below that needed to open the pressure relief valves and 
result in the discharge of the alcohol. Similarly, the manways, if properly 
secured, should withstand the rated pressure of the tanks, 100 psig, and 
should not have leaked under the static pressure calculated. 

During the collision and derailment, both tank cars were subjected to 
dynamic forces that would have caused the alcohol in each tank car to surge 
toward the leading end. The void spaces of the manway and the leading 
pressure relief valve would be instantaneously filled with the surging 
alcohol and subjected to increasing pressure as the liquid continued to surge 
forward. The two pressure relief valves observed to be leaking were both on 
the leading end of the two tank cars - the pressure relief valve observed by 
the two police officers moments after the accident was the leading valve on 
ADMX 29477, and the pressure relief valve observed to be leaking by a Safety 
Board investigator on August 2 was the leading valve on ADMX 29494. 



60 

However, the magnitude of the internal dynamic forces generated in this 
accident are unknown. Calculation of dynamic loading forces on manway, 
pressure relief valves, and other closure fittings on a tank car is not 
required or done as part of the tank design or certification process. 
Further, the tank car manufacturer has indicated that dynamic loading 
calculations could not be "readily" done to estimate the dynamic loads in 
this accident. Consequently, not only are the dynamic loading forces 
generated in this accident unknown, but whether the fittings on either tank 
could have withstood dynamic loading forces encountered in this accident is 
also unknown. 

Since the manways on the two cars were opened during the salvage 
operations, and all of the fittings on the top of the tank cars had been 
exposed to heat and fire, it is unknown whether the pressure relief valves 
and the manways had been properly secured at the time of the accident. 

Tank Car Performance during Postaccident Testing . --During the post- 
accident hydrostatic tests conducted on the tank cars at Longview, Texas, it 
was noted that considerable effort was expended by the workers to tighten 
bolts around the manway cover to a point that both cars successfully held 
100 psig for over 10 minutes. Given the effort required to seal the manway 
during this test, the Safety Board questions the effectiveness of the 
securement design, and is concerned that the typical loader may not exert the 
effort required during the hydrostatic tests to secure the manway. 

The recorded torque to loosen each of the pressure relief mounting 
bolts indicate that three of the four valves were not seated evenly when the 
pressure relief valves were being removed for bench testing. Since the 
pressure relief valves had been exposed to fire and there was some 
degradation of the gaskets at the mounting interfaces, the uneven torque 
values do not precisely reflect the pre-accident condition of the mounting 
bolts and flanges. The torque values do indicate, however, that the mounting 
bolts for the pressure relief valves likely were not evenly torqued when the 
accident occurred. Without specified torque values to obtain a liquid/vapor 
seal, it cannot be determined whether a proper seal existed at any of the 
mounting surfaces for the pressure relief valves. 

The results of the bench tests of the pressure relief valves indicate 
that three of the four valves opened and reseated close to design 
specifications. The fourth valve, which was on the A-end of ADMX 29477, 
opened at 73 psig, but did not reseat until pressure had fallen to 30 psig. 
The valve should reseat at 60 psig. Since this particular valve was located 
in an area where the tank shell had been scorched and subjected to heat, the 
failure of the valve to reseat within specifications may have been the result 
of heat damage. 

The pressure relief valves (with one exception) operated satisfactorily 
when they were oriented in a vertical position. However, without testing the 
valves in different orientations, the performance of the valve in positions 
other than the vertical cannot be ascertained. 



61 

Consequently, the Safety Board cannot positively conclude that the 
leakage was caused by excessive internal forces generated during the 
derailment, improperly secured manways, improperly mounted pressure relief 
valves, or a performance deficiency of the pressure relief valves. However, 
because of the minimal structural damage to the tanks and the leakage that 
did occur, the Safety Board assessed the adequacy of ADM's procedures for 
loading and preparing tank cars for transportation, and the adequacy of 
Federal regulations regarding the performance and design of closure fittings 
on hazardous materials rail tanks. 

Tank Car Securement Procedures and Training at ADM's Cedar Rapids Plant 

The investigation of this accident revealed that the loading of 
hazardous materials into tank cars at ADM's Cedar Rapids plant was performed 
by operators with minimum supervision from their immediate supervisor, the 
foreman of alcohol production at the plant. The foreman acknowledged that, 
aside from the operator loading the tank car, no other employee at the plant 
routinely inspects the manway or valves on the tank cars before the tank car 
is released to the railroad. The foreman's statement that he will go to the 
loading area only if there is a problem, and the superintendent's statement 
that he depends upon the competency of the foreman and the loader to properly 
load the tank cars suggest that there is no effective supervision and 
evaluation of the loader's performance. 

The investigation also revealed that written procedures for loading 
tank cars that existed at the time of the accident were minimal. Further, 
even the procedures put in writing following the accident do not provide 
sufficient guidance to be effective. For example, there are no criteria for 
operators to determine when manway gaskets should be changed, and the written 
guidance for securing the manways does not specify whether manway bolts 
should be evenly torqued or how much torque should be applied. The written 
procedures also do not require the operator to check whether the mounting 
bolts for the pressure relief valves are torqued, or otherwise provide 
guidance about the pressure relief valves. While ADM does not concede that 
it is necessary to have loading procedures in writing and the corporate 
office has provided little guidance on this issue to any of its plants, the 
Safety Board is concerned that without detailed written procedures, the 
loading of tank cars becomes a far too subjective activity. The Safety Board 
believes that this is particularly true when the only type of training given 
to the operators is on-the-job training. 

The Safety Board found in its investigation of a vinyl chloride monomer 
tank car fire at the Formosa Plastics Corporation plant in Baton Rouge, 
Louisiana, on July 30, 1983,^2 ^^at the failure to provide written 
procedures for its loading employees contributed to the cause of the 
accident. The Safety Board, consequently, recommended that the Formosa 
Plastics Corporation: 



3 2 

Railroad Accident Report-- "Vinyl Chloride Monomer Release from a 

Railroad Tank Car and Fire, Formosa Plastics Corporation Plant, Baton Rouge, 
Louisiana, July 30, 1983" ( N T SB/R AR - 85 / 08 ) . 



62 



R-85-65 

Establish a training program and loading turnover 
procedures for supervisors and employees assigned to load 
hazardous materials for transportation. 

The Formosa Plastics Corporation subsequently developed a training program 
and developed procedures and a checkoff list to be used for its employees in 
the loading of the tank cars. As a result, the Safety Board placed the 
recommendation in a "Closed--Acceptable Action" status. 

While the Board cannot conclude whether the manways had been adequately 
secured by ADM before releasing ADMX 29477 and ADMX 29494 for transportation, 
or that the pressure relief valves were mounted securely, the Safety Board 
believes that the absence of detailed written procedures, of an adequate 
employee training and evaluation program, and of appropriate corporate 
oversight increases the likelihood of future releases of hazardous materials. 
The Board believes that ADM should develop detailed written procedures for 
loading and preparing rail tank cars for transportation and to develop and 
implement employee training and evaluation programs consistent with the 
written procedures. Furthermore, in view of the deficiencies noted at the 
Formosa Plastics Corporation's plant and at ADM's Cedar Rapids plant, the 
Safety Board is concerned that the problems may be widespread in the 
industry. Accordingly, the Safety Board believes that the Chemical 
Manufacturers Association and the National Industrial Transportation League 
should inform its membership of the circumstances of this accident and 
encourage its members to develop written procedures for loading and preparing 
tank cars for transportation and to implement employee training and 
evaluation programs consistent with the written procedures. 

Federal Regulations Regarding Performance and Design of Closure Fittings on 
Hazardous Materials Rail Tanks 

Existing tank car design specifications in 49 CFR Part 179 do not 
address accident performance standards, particularly with respect to closure 
fittings on tank cars, or require that dynamic loads be calculated to 
determine if a tank car and its fittings can withstand the dynamic forces 
generated by liquid surging or sloshing in a derailment or overturning. 
Since calculation of the loading forces on the manways and other closures is 
not required or done as part of the tank design or approval process, the 
Safety Board could not determine if the dynamic forces generated in this 
accident exerted pressures that would have exceeded the rated pressures of 
the relief valves and the manways, had they been properly secured. Secondly, 
the performance of the pressure relief valves has been tested only in a 
vertical position. The performance of these relief valves in positions other 
than the vertical has not been proven, particularly since one pressure relief 
valve observed to be leaking in a horizontal position later performed nearly 
to manufacturer's specifications in a vertical position during the bench 
tests. The Safety Board believes that in accidents that are survivable by 
the rail tank, particularly with the small amount of structural damage as 
seen in this accident, it is reasonable to expect the closure fittings on the 



63 

rail tank to maintain their integrity as well. Accordingly, the Safety Board 
urges that the FRA, with the cooperation and assistance of RSPA, amend 49 CFR 
Part 179 to require that closure fittings on hazardous materials rail tanks 
be designed to maintain their integrity in accidents that are typically 
survivable by the rail tank. 

The ability to mount bolted supports for fittings such as pressure 
relief valves and or to secure bolted fittings such as manway openings to 
provide a liquid or vapor tight seal depends upon tightening the fastening 
bolts not just so that they appear secure, but to the proper torque levels. 
Further, this requires the use of gaskets of the proper dimensions, 
thickness, and material. Therefore, the Safety Board also urges that the 
FRA, with the cooperation and assistance of RSPA, amend 49 CFR Part 179 to 
require that tank car designers and manufacturers determine and provide the 
specifications to secure closure fittings, such as minimum torque values for 
sealing bolted closures and gasket specifications. 

Positioning of Tank Cars Within a Train 

When the crew of Extra 470 West made up the train in Newton on the 
morning of the accident, they failed to position properly the two alcohol 
tank cars. After setting out a car in Colfax, the crew again failed to 
reposition the two tank cars in the middle of the train leaving the two tank 
cars even closer to the locomotive. Since the cars immediately following the 
two tank cars did not derail during the collision, it is reasonable to assume 
that the two tank cars, had they been the fourth and fifth cars behind the 
locomotive upon leaving Newton, may not have derailed. Although the 
positioning of the tank cars was not a factor in the cause of the accident, 
the position of the tank cars resulted in their derailment, the subsequent 
release of hazardous materials, and the resulting fire. The release of the 
alcohol and the fire prolonged the duration of the emergency and increased 
risk to life and property. Further, the bodies of the crewmembers of Extra 
470 West were found under the tank cars, and the autopsy reports attributed 
the cause of death to crushing. Since the Safety Board could not determine 
if the crewmembers of Extra 470 West jumped from their locomotive prior to 
the collision or were thrown from the locomotive during the collision 
sequence, the Safety Board could reach no conclusion concerning what role the 
positioning of the tank cars had in terms of the death of the crewmembers. 

Federal regulations address the positioning of placarded tank cars in 
trains, and the lAIS had included these instructions in its timetable. Both 
the superintendent of operations and the assistant superintendent of 
operations at Newton stated, however, that, based on their interpretation of 
the regulations, the tank cars should have been the last two cars of the 
train. The Federal regulations as currently written, however, do not 
address the positioning of placarded tank cars in a cabooseless train. The 
lAIS officials' interpretation of the regulations gives credence to the 
Safety Board's position that current regulations need to be revised to 
address the placement of tank cars carrying hazardous materials on 
cabooseless trains. 



64 

The Safety Board believes that positioning placarded cars at the end of 
a cabooseless train poses significant hazards. One purpose of positioning 
placarded cars in the middle of a train is to separate them from the occupied 
locomotive and caboose. With the elimination of cabooses, the rear of the 
train does provide the greatest separation from the crew in the locomotive. 
However, the Safety Board believes that there is a need to buffer placarded 
cars not only from head-on collisions but from rear-end collisions as well to 
protect the head-end crew of the striking train. The Safety Board has 
previously expressed concern about placement of hazardous materials cars at 
the rear of cabooseless trains and recommended that RSPA: 

R-87-17 

Change the current railroad hazardous material car 
placement regulations in 49 CFR Part 174, Subpart D, to 
read "end-of-train" in lieu of "occupied caboose." 

RSPA, in its response of March 1, 1988, to the recommendation, indicated 
that it would work with the FRA to develop and issue an Advance Notice of 
Proposed Rulemaking (ANPRM) on the subject of the safety recommendation. 
Based on this indication, the safety recommendation was classified as "Open-- 
Acceptable Action" on April 25, 1988, pending the change in the regulations. 
As of this report, RSPA has not issued an ANPRM, and no date has been 
provided for the issuance of the ANPRM. In view of the lack of progress to 
achieve the intent of this safety recommendation, it is now being held in an 
"Open--Unacceptable Action" status. Because this accident again indicates 
the need for RSPA to act, the Safety Board reiterates Safety Recommendation 
R-87-17. 

Emergency Response 

The emergency response to the accident was timely, and the various 
emergency response agencies coordinated their efforts and activities 
throughout the incident. The City of Altoona had an up-to-date disaster plan 
which was successfully implemented. 

Survival Aspects/Crashworthiness 

The locomotive cab compartment of unit 470 was destroyed when it was 
overridden in the front by unit 406 and in the rear by the trailing covered 
hopper car. The Board's investigation could not determine if the crewmembers 
of Extra 470 West jumped before the collision or were thrown from the 
locomotive cab during the collision sequence. Regardless of the scenario, 
because of the damages to the locomotive unit, the accident was not 
survivable for the crewmembers of Extra 470 West. 

The crewmembers of Extra 406 East survived the accident. The engineer 
jumped before the collision and cleared the immediate area before the initial 
impact. The conductor remained inside the cab compartment during the 
collision sequence. Since unit 406 was the overriding unit, there was 
sufficient survivable area within the cab and the conductor sustained only 



65 

minor injuries. He was able to extricate himself from the cab compartment 
before the postcollision fire impinged upon the locomotive unit. 

The covered hopper car behind unit 470 apparently elevated on impact, 
slipped by the standard type E (nonshelf) coupler and overrode the short hood 
of the locomotive, completely destroying the cab area. A 1982 study prepared 
for the FRA concluded that one possible means of mitigating the override 
problem was to install shelf couplers on locomotives. The Safety Board 
cannot definitively conclude that had the locomotive been equipped with a 
shelf coupler the fatalities would have been prevented. However, the Safety 
Board believes that the FRA should promulgate regulations requiring that 
locomotives be equipped with shelf couplers compatible in strength with the 
main frame sill of the locomotive. 

Event Recorders 

The lack of event recorders on the lAIS locomotives prevented the Safety 
Board from determining the speed of either train at the time of the 
accident, whether the trains were being operated according to the operating 
rules, and, thus, whether the speed of either train contributed to the 
accident or its severity. The Safety Board's position regarding the use of 
event recorders in the railroad industry has been well documented in previous 
accident investigations, through the issuance of safety recommendations to 
the industry and the FRA, and in comments on Federal rulemaking proposals. 
The Safety Board continues to believe that event recorders are not only an 
invaluable investigative tool in determining the cause of accidents and 
preventing future accidents but a management tool that can be used to monitor 
compliance with operating rules, particularly speed restrictions. 

The Safety Board believes that the Rail Safety Improvement Act of 1988 
mandates rules requiring event recorders and that it does not give the FRA 
freedom to decide whether Federal regulatory intervention on this subject is 
necessary. The Board is concerned, based on the FRA's past considerations of 
this issue, that FRA will arbitrarily decide that Federal regulations are not 
justified or warranted. The Board believes that the intent of Congress is 
explicit and that the FRA should take immediate action and issue the 
rulemaking requiring event recorders in the railroad industry. 

Toxicological Testing 

The results of the toxicological testing of the crewmembers of Extra 406 
East were negative. Ethanol was detected in the tissue samples of both 
crewmembers of Extra 470 West but was attributed to bacterial contamination. 
The dispatcher and train order operator working on the day of the accident 
were not requested to submit to toxicological testing. While there is no 
evidence to indicate that these individuals were or were not impaired, the 
Safety Board is concerned that all individuals in safety sensitive positions 
were not requested to submit to toxicological testing, as required by Federal 
regulations. The positions of dispatcher and train order operator are 
critical to the safe operation of trains, particularly on a "dark" railroad. 
Management's failure to require that these individuals submit to 



66 

toxicological testing may have been the result of management not being 
thoroughly familiar with Federal regulations. 

CONCLUSIONS 

Findings 

1. No mechanical defects were evident on the equipment of either train 
that would have contributed to the accident. 

2. No anomalies or deficiencies were evident in the track structure or 
track geometry that would have contributed to the accident. 

3. The crew of Extra 406 East departed Altoona before the time 
permitted in train order 213. 

4. Alcohol and drugs were not a factor in this accident. 

5. Having been on duty for nearly 10 hours and having received only 4 
or 5 hours of sleep the night before, the crew of Extra 406 East 
could have been fatigued and preoccupied with going off duty when 
they departed Altoona. 

6. The crew of Extra 406 East did not discuss and verify the contents 
of train order 213, as required by company rules. 

7. The Iowa Interstate Railroad does not equip its locomotive units 
with event recorders; consequently, the speed of either train at 
the time of the collision could not be determined. 

8. Because of the extensive alteration of the foliage and the 
embankment in the accident area during the wreckage clearing, the 
precise distance at which the crews of Extra 406 East and Extra 470 
West would have been able to see each other could not be 
determined. 

9. The operation of Extra 470 West was not a causal factor in the 
accident. 

10. Based on the time of the accident and the location of the accident, 
Extra 470 West had more than sufficient time to travel the 
distance to Altoona before Extra 406 East was to depart from that 
location. 

11. The Federal Railroad Administration failed to follow up with the 
Iowa Interstate Railroad (lAIS) to resolve the status of the lAIS 
request regarding the signal system. 

12. The Iowa Interstate Railroad, knowing that it had only received 
temporary relief from the Federal Railroad Administration to 
operate without a signal system, failed to follow up with the 
Federal Railroad Administration and request permanent relief. 



67 



13. Had Extra 406 East been given authority in the train order to 
operate only as far as Altoona and then been required to contact 
the dispatcher and obtain permission to proceed east of Altoona, 
the accident could have been prevented. 

14. The process by which train orders were issued to Extra 470 West on 
the day of the accident did not enable the dispatcher, who is 
responsible for the movement of trains over the territory, to be 
certain that the train orders were received by the crewmembers. 

15. The Iowa Interstate Railroad did not maintain a record of train 
movements, as required by Federal regulations. Consequently, on 
the day of the accident, the dispatcher had no way of knowing when 
and if Extra 470 West had departed its initial terminal. 

16. Yard limits for Altoona Yard had only been established by a general 
order, but no yard limit signs had been installed to designate the 
physical limits of the yard. 

17. Management had not installed yard limit signs at Altoona to alert 
crews of where to begin to operate at restricted speed. 

18. Although required by company rules and Federal regulations, tests 
of the train air brake system were not being conducted by Iowa 
Interstate Railroad operating crews on a regular basis. 

19. Iowa Interstate Railroad management did not provide any guidance or 
instructions for conducting air brake tests with an end-of-train 
device in cabooseless operations. 

20. The operating rules training program used on the Iowa Interstate 
Railroad was ineffective and failed to determine that operating 
employees were sufficiently knowledgeable of the operating rules. 

21. The training program instituted by the Iowa Interstate Railroad to 
promote individuals to the position of engineer was deficient 
because (1) the trainee's exposure to locomotive operations was 
limited since he was required to perform the duties of conductor 
during this time, (2) management failed to evaluate the performance 
of trainees, and (3) management failed to provide adequate 
instructions and guidance to the engineer instructors. 

22. Iowa Interstate Railroad management provided inadequate supervision 
of its train operations and failed to perform efficiency testing 
of its operating employees. 

23. The Federal Railroad Administration failed to oversee adequately 
railroad operations on the Iowa Interstate Railroad and failed to 
take enforcement action against the Iowa Interstate Railroad for 
noncompliance with Federal regulations. 



68 



24. The Federal Railroad Administration did not have a system in place 
to follow up on defects noted on field inspection reports to verify 
that corrective action has been taken or to alert Federal Railroad 
Administration officials of a carrier's noncompliance with Federal 
regulations or trends in a carrier's operations. 

25. Although Iowa Interstate Railroad crews operated over trackage of 
the Chicago North Western, the CSX, and METRA, these railroads had 
not determined if Iowa Interstate Railroad crews were qualified to 
operate over their respective territories. 

26. Management of the Iowa Interstate Railroad was not familiar with 
Federal accident/incident reporting requirements and, as a result, 
provided no guidance or written instructions on the reporting of 
accidents. 

27. Shippers of hazardous materials are often unaware of problems or 
incidents involving their containers because existing regulations 
do not require carriers to notify shippers of reportable hazardous 
materials incidents. 

28. The leaking and burning of product from the tank cars, while not a 
factor in the cause of the accident, increased the danger and 
severity of the accident, prompting local emergency response 
personnel to evacuate nearby residents. 

29. Written procedures for loading and securing tank cars at Archer 
Daniels Midland's Cedar Rapids plant that existed at the time of 
the accident were minimal and the procedures put in writing 
following the accident do not provide sufficient guidance to be 
effective. 

30. Management at Archer Daniels Midland's Cedar Rapids plant had not 
taken sufficient actions to ensure that tank cars leaving its 
facility were properly prepared for transportation as required by 
Federal regulations. 

31. Current Federal regulations do not adequately address the 
positioning of loaded placarded tank cars in cabooseless train 
operations. 

32. Denatured alcohol leaked from the manways and the pressure relief 
valves on two tank cars during the derailment and overturning 
despite the minimal damage to the rail tanks. 

33. Existing tank design specifications for closure fittings on 
hazardous materials tank cars do not adequately ensure the 
integrity of fittings in accidents that are survivable for the 
tank. 



69 

34. The emergency response was timely and the various emergency 
response agencies coordinated their efforts and activities 
throughout the accident. 

35. Had the locomotive of Extra 470 West been equipped with a shelf 
coupler, the overriding of the locomotive by the covered hopper car 
would probably not have occurred and the fatalities may have been 
prevented. 

36. The accident was not survivable for the crewmembers of Extra 470 
West. 

Probable Cause 

The National Transportation Safety Board determines that the probable 
cause of this accident was the failure of the traincrew of Extra 406 East to 
comply with the wait provisions of train order 213 and Iowa Interstate 
Railroad's (lAIS) inadequate oversight and enforcement of its operating 
rules. Contributing to the traincrew's failure to comply with the wait 
provisions was a combination of fatigue induced by irregular work/rest 
schedules, preoccupation with completing their assignment prior to exceeding 
duty time limits, inexperience, "mental set" or expectations based on 
previously issued train orders, the work activities which intervened since 
they received the train order, and the lAIS's inadequate training of its 
crews. Contributing to the accident was the Federal Railroad 
Administration's inadequate surveillance and enforcement of compliance by 
the lAIS with Federal regulations. Contributing to the length of the 
emergency was the release and burning of hazardous materials from pressure 
relief valves and manways on the tank cars. 

RECOMMENDATIONS 

As a result of its investigation of this accident, the National 
Transportation Safety Board made the following safety recommendations: 

--to the Iowa Interstate Railroad: 

Install yard limit roadway signs at Altoona and other 
areas designated in general orders and show designated 
limits in the timetable. (Class II, Priority Action) 
(R-89-37) 

Remove, cover, or turn away from the track, all out of 
service signals. (Class II, Priority Action) (R-89-38) 

Require that train order operators verify to the 
dispatcher that train orders have been received by 
operating crews. (Class II, Priority Action) (R-89-39) 



70 

Establish and enforce procedures for dispatchers to 
maintain an accurate and up-to-date record of train 
movements, as required by Federal regulations. 
(Class II, Priority Action) (R-89-40) 

Provide written instructions and training to operating 
personnel for conducting air brake tests with an end-of- 
train device in cabooseless operations. (Class II, 
Priority Action) (R-89-41) 

Develop and implement a comprehensive program of training 
and testing of the company's operating rules, in 
accordance with the provisions of the Federal 
regulations. (Class II, Priority Action) (R-89-42) 

Develop and implement a program of supervision and 
management of train operations to include efficiency 
checks of traincrews, as required by Federal regulations. 
(Class II, Priority Action) (R-89-43) 

Develop explicit written procedures concerning the 
Federal agencies to be contacted in the event of a 
railroad accident/incident on the Iowa Interstate 
Railroad. (Class II, Priority Action) (R-89-44) 

-to the Federal Railroad Administration: 

Conduct a safety audit of the Iowa Interstate Railroad. 
(Class II, Priority Action) (R-89-45) 

Resolve the status of the signal system on the Iowa 
Interstate Railroad. (Class II, Priority Action) 
(R-89-46) 

Develop and implement a program that will (1) provide 
consistent followup of defects noted on inspection 
reports to verify that corrective action has been taken, 
(2) outline in detail the responsibilities of field and 
headquarters personnel regarding defects and violations 
noted, and (3) alert FRA officials of carriers' 
noncompliance with Federal regulations and trends in 
carriers' operations. (Class II, Priority Action) 
(R-89-47) 

Assist and cooperate with the Research and Special 
Programs Administration in amending 49 CFR Part 179 to 
require that closure fittings on hazardous materials rail 
tanks be designed to maintain their integrity in 
accidents that are typically survivable by the rail tank. 
(Class II, Priority Action) (R-89-48) 



71 

Assist and cooperate with the Research and Special 
Programs Administration in amending 49 CFR Part 179 to 
require that specifications for securing closure 
fittings, such as minimum torque values for sealing 
bolted closures and gasket specifications, be determined 
and provided by tank car designers and manufacturers. 
(Class II, Priority Action) (R-89-49) 

Expedite the rulemaking requiring the use of event 
recorders in the railroad industry. (Class II, Priority 
Action) (R-89-50) 

Promulgate regulations requiring that locomotives be 
equipped with shelf couplers compatible in strength with 
the main frame sill of the locomotive. (Class II, 
Priority Action) (R-89-51) 

--to the Research and Special Programs Administration: 

Establish procedures that require carriers reporting 
hazardous materials incidents under the provisions of 49 
CFR 171.16 to notify shippers whose hazardous materials 
shipments are involved. (Class II, Priority Action) 
(R-89-52) 

Assist and cooperate with the Federal Railroad 
Administration in amending 49 CFR Part 179 to require 
that closure fittings on hazardous materials rail tanks 
be designed to maintain their integrity in accidents that 
are typically survivable by the rail tank. (Class II, 
Priority Action) (R-89-53) 

Assist and cooperate with the Federal Railroad 
Administration in amending 49 CFR Part 179 to require 
that tank car designers and manufacturers determine and 
provide the specifications to secure closure fittings, 
such as minimum torque values for sealing bolted 
closures and gasket specifications. (Class II, Priority 
Action) (R-89-54) 

--to the Archer Daniels Midland Company: 

Develop written procedures for loading and preparing rail 
tank cars for transportation at the various plants and 
develop and implement employee training and evaluation 
programs consistent with the written procedures. 
(Class II, Priority Action) (R-89-55) 



72 

--to the Chemical Manufacturers Association and the National Industrial 
Transportation League: 

Inform its membership of the circumstances of the train 
accident and the release of hazardous materials at 
Altoona, Iowa, on July 30, 1988, and encourage its 
members to develop written procedures for loading and 
preparing rail tank cars for transportation and to 
develop and implement employee training and evaluation 
programs consistent with the written procedures. 
(Class II, Priority Action) (R-89-56) 

--to the American Short Line Railroad Association: 

Inform its membership of the circumstances of the train 
accident and the release of hazardous materials at 
Altoona, Iowa, on July 30, 1988. (Class II, Priority 
Action) (R-89-57) 

Disseminate to its membership accident/incident 
notification criteria of all Federal agencies. 
(Class II, Priority Action) (R-89-58) 

--to the Association of American Railroads: 

Inform its membership of the circumstances of the train 
accident and the release of hazardous materials at 
Altoona, Iowa, on July 30, 1988. (Class II, Priority 
Action) (R-89-59) 

Cooperate with the Federal Railroad Administration in 
promulgating regulations requiring the installation of 
shelf couplers on locomotives. (Class II, Priority 
Action) (R-89-60) 

--to the Chicago North Western Transportation Company, the CSX 
Transportation Company, and METRA: 

Determine that operating employees of other railroads are 
appropriately qualified to operate over trackage of your 
railroad. (Class II, Priority Action) (R-89-61) 

As a result of its investigation of this accident, the Safety Board also 
reiterated the following Safety Recommendation to the Research and Special 
Programs Administration: 

Change the current railroad hazardous material car 
placement regulations in 49 CFR Part 174, Subpart D, to 
read "end-of-train" in lieu of "occupied caboose." 
(Class II, Priority Action) (R-87-I7) 



73 
BY THE NATIONAL TRANSPORTATION SAFETY BOARD 



hi 


James L. Kolstad 






Acting Chairman 




/s/ 


John K. Lauber 
Member 




/s/ 


Joseoh T. Nail 

Member 




/s/ 


Lemoine V. Dickinson. 


Jr. 




Member 





July 6, 1989 

Member Burnett filed the following dissenting statment: 

I do not concur in the adoption of the report and its probable cause 
because we have not yet satisfactorily completed the investigation. Our 
investigation establishes that the Federal Railroad Administration (FRA) 
failed to do its job, which in turn led to this accident. Until we interview 
the appropriate officials within the FRA and until we probe and assess the 
FRA's decisionmaking processes that allowed the Iowa Interstate Railroad to 
operate in noncompliance with Federal regulations, this investigation will 
fall short of the standard that it should achieve. 

We should have awaited the completion of the investigation before 
adopting the probable cause. 

/s/ Jim Burnett 

Member 



July 12, 1989 



75 
APPENDIXES 
APPENDIX A 
INVESTIGATION AND HEARING 



Investigation 



The National Transportation Safety Board was notified at 2:30 p.m., 
eastern daylight time, on July 30, 1988, of a head-on collision and 
derailment of two Iowa Interstate Railroad freight trains with a fire and 
evacuation in progress at Altoona, Iowa. The investigator-in-charge and 
other members of the investigative team were dispatched from the Washington, 
D.C. office and field offices in Altanta, Georgia, and Fort Worth, Texas. 
Investigative groups were established for engineering, mechanical, 
operations, human performance, survival factors, and hazardous materials. 

Hearing 

The Safety Board staff conducted a deposition proceeding as a part of 
its investigation of this accident on October 18, 19, and 21, 1988, at Des 
Moines, Iowa. Parties to this proceeding included the Iowa Interstate 
Railroad, the Federal Railroad Administration, the United Transportation 
Union, and the Archer Daniels Midland Company. The Iowa Interstate Railroad 
chose not to appoint a party spokesperson during the proceedings. Four Iowa 
Interstate Railroad officers required a federal court order before presenting 
testimony. Twelve witnesses testified. 



76 

APPENDIX B 

PERSONNEL INFORMATION 

Engineer, Extra 406 East 

Engineer Dennis L. Schrader, age 47, advised that he had been diagnosed 
as having coronary artery disease in 1987, for which he successfully 
underwent coronary angioplasty. His lAIS physical examination record, dated 
November 11, 1986, disclosed no adverse medical condition, and reported that 
his vision and hearing were within normal limits. 

Conductor, Extra 406 East 

Conductor Orville E. Harger, age 51, underwent a physical examination on 
November 13, 1984. The record disclosed no adverse medical condition and 
reported that his hearing and corrected vision were within normal limits. 

Engineer, Extra 470 West 

Engineer Larry D. Buckingham, age 35, underwent a physical examination, 
dated October 24, 1986. The lAIS record disclosed no medical problems and 
reported vision and hearing to be within normal limits. 

Conductor, Extra 470 West 

Conductor William J. Peers, age 54, certified on his employment 
application, dated August 7, 1987, that he had no physical or mental 
condition which limited or impaired his ability to perform his duties. There 
was no lAIS record of a physical examination on file for Conductor Peers. 



77 
APPENDIX C 
IOWA INTERSTATE RAILROAD TIMETABLE NO. 2 (EXCERPTS) 



IOWA INTERSTATE 
RAILROAD LTD. 



SYSTEM 

TIMETABLE 

NO. 2 



IOWA 

lAIS 



INTERSTATE 



Effective 0001 

Wednesday, April 15, 1987 

Central Standard Time 



FOR THE GOVERNMENT OF 
EMPLOYEES CONCERNED. 



SAFETY FIRST. . .ALWAYS 



APPENDIX C 



78 



MAIN LINE tUBDIVIStON NO. S 


SYSTEM 1 








M* 






iMfBl*! 




*M 




MMtoi 


0«MC 




Pmm 




Ma. 


•Mk« TiU. 


•UUw* 


Ctm. 


mm» 


Oil 




Virt 


Nmaa 
UJ 


m.i 


BCPW 


aj5 


mo 


wm 
mo 


S.t 


IM.7 




•41 




■im 




*40.» 




nti 




tiro 

7J0 


Akoeu 

S.* 
MPUOJ 


M.* 
J50.I 


WW 


tm 






11.7 






0M4 






MP1M.5 
1.2 


M4.5 


p 


em 


MO 




■«e»»Mii 

7.1 


I7I.7 




oito 




400 


OtSMO 
57 


J7t.l 




OM* 


ijeo 




WiMW 

l.t 


HS.S 




or 


MOO 


1000 


Evthui 
5.4 


ir.4 


• 


Otl 




mo 


Drib 
5J 


mo 




mi 


4000 


WHO 


Iiiiin 
5.1 


m.2 




•101 


4S00 




EMiMak) 
14 


401.5 




pta 




1000 


Male 
7.0 


40.1 




MIO 




wiooo 
mo 


4.7 


410.1 




MP 




wmo 


Adur 
17 


414.1 




•tit 


mo 


MO 


Aaiu 
144 


4X5.5 




••40 




Ywd 


AttUlK 

0.1 

AaiukeaJa 
I4.« 


4M.t 

440.7 


•CPWC 


MM 


mo 




HiOu 
5.7 


455.4 




MM 




Ywd 


HMOock la 
15.4 


454.5 






uoo 




hin 
l.t 


474.7 




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wim 


McOdlnd 

11.4 

Hum 


4H.I 




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Vird 


4n.o 










ItS.S 




YDK 



Rag Protection Dlatane* 1 mil* 
Maximum Spa^d: 40 mph 



SPEED RESTRICTIONS 
Sulxlivision: 3 

MP trJtonS 30MPH 

SPECIAL INSTRUCTIONS 
Subdiviiioo: 3 

YARD UMITS 

Newioo MP 320 to 325 

Blufft MP«i6.llo490 



BawecD MP 330.1 and MP 364.3 trains and csfina wID be 
tovcraed by timcuble and nilct of the CNW Transponatioo Co. 
and DMU R.R. Ptnniisioo from the CNW yardmastcr muit be ob- 
tained before coierint tbcie bmiu. Pboocs located ai Ahooaa and 
MP3M.3 

Base radio at Blufft ofwrativc OBOO tiD 2300 bom daDy. 

INDUSTRIAL TRACK OR SPUR TRACK 

LOCATED BETWEEN STATIONS. 
MP 440.1 Allied Mills ElOOO 



eontlnvd on P»g» 11 



MS-'C 



ant 

9M.« 



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toil* iht.1 lar 



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w)- .futWnr-HttM-t^ — L-gag"* 




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UlT Dti M0MCS'7»0Xr.r-»r-» 
iHOIkT UNt jcr. 



ta*M»* 



•MOM6rodt 



'rklttllriimUS 



• ••«^4>«<T» 




TIMETABLE NO. 2 



TIMETABLE NO. 2 



79 APPENDIX C 



«»*ECIAL IMSTWUCnONS 



cuncnt inin locatioo Une^p wiD be pcnnitied lo enter the lioiiu of 
nch liiic-up durint the time the tine-up it ia cffen. 

Is otertency siuatioat, wben k beoones necetury to operate a 

train or cncine duriat tune line-up k in cfTect and nicb train or 

angiiie to not shown oocurrcnt line-up an oflioer ihould ride the 

«fine whenever poniblc and ditpatcbcr Bust inue Train Order to 

the train or cafine as follows: 

"Track car operaton have bo notice of your train (or engine) on 

Uae-up. "Run watdiinc for track can toundint whittle fredy." 

Dispatcher mutt take necessary action to prevent traiiu or engines 

nmning in advance of the figures shown at the statiotu designated 

on line-up when necessary, protecting the figures shown by Form 

"E" Train Order (Hae Order). 

Train dispatchers than bsue line-ups for aD concerned at times 
ipedried by the Superintendent and will be written in train order 
biook numbered ooiuecutively beginning at midnight. Additiona] 
line-upt will be issued upon request. When line-ups previously iuued 
are itill in effect when dispatchers are relieved, transfer must show 
numbers of line-upi in effect and relieving Dispatchen will be 
rcspoosibie for traiiu operating not shown on line-up or traiiu 
operating ahead of line-up figures. Line-up must be repeated by one 
or ntorc of those copying it. Eadi person copying line-up must 
observe whether Une-up it repeated correctly and, if not, will im- 
Dcdiatdy call attention to any mistakes. 

At designated intervals, copies of bne-i^ wiD be mt to a 
designated super>asory officer for checking. 



Persons copying line-ups shaD make as many copies at aecettary. 
When an operator copies line-up. a file copy thall be retained bear- 
ing tignature of all pertont to whom copies were issued, and when 
relayed by phone or other communication, notation will be made on 
file copy. 

When necessary, foreman shall obtain enra copies of line-ups for 
use by employees under their supervision. Such emidoyeet shall 
acknowledge receipt and understanding of the Une-up by signing the 
foreman't copy. 

rTEM (5) All SabdlvWou: 

1. Hi rail equipment may be operated with one man. 

2. The Following Letters and Symbolt Indicate: 
A Automatic Interlocking 

B Genera] Order Boards ar Books 

C Standard Clock 

F Fuel Sution 

M Manual Interlocking 

P Telephone 

T TurauMe 

UX Railroad crossing ikm protected by interlocking 

W Water station 

Y Wye 

YD Sution where yark limiu are maintained. 

Wayside Radio 

K) BaK Radio 



S. Train or cnginemen will communicate with dispatcher within 
(10) ten minutes after arrival at meeting points unleu expected train 
is heard or seen approaching. 



It TIMETABLE NO. 2 



APPENDIX C 80 



tPECUl IMSTWUCnOMS 



A iracn rannBc ipced tifp «fll be ditpUyvd to the rifhi of «efa 
mck ai the lunit of rcRrictioa. Rotrioed tpeed mutt dm be cxcHd- 
id Ihrough t^ tcniiory aaraed in the orda unleu ■ diffacat ^aad 
ii orally autborind by foraaan to charge. PraKribed ipced wtU not 
be ocBTdad mil tntirc train hai pataed the mumc ipced liin. 

A traio or CQgiBC withio Kmlu of a Fom y eumplc (3) order at cf- 
faciivc liac of order, Buit im( proceed unleu oraDy autboriiad by 
forcmao to charge of work, or a proceed Bgnal with graeo flag or 

Where "PROCEED PREPARED TO STOP" and **06hD1- 
T10NAL STOP" aignt arc disptoyad. they must be ropeeted even 
though no Fom y aample (3) train order u bdd Where a Form y 
alumpie 0) ii to cffaci and the "Cooditiooal Stop" rign ii not 
ditplayad, or when proceed piepa ia d to Mop agn a displayed and no 
Form y example (3) nte effact. itop must be made ai location where 
"CONDITIONAL STOP" agn riwuld be located, and train must 
•01 proceed untO orally authoritad or receiva a proceed Bgnal with 
a green flag or light. 

Before orally authorizing train to proceed, foreman must inform 
the engineer the speed permitted over the reetricted track. 

Oral authorization and acknowledgment betwe en foremen and 
engineen for trains to past "CONDITIONAL STOP" sgns mutt be 
made to the manner prcKribed by form shown to special iastruc- 

tiOBS. 

Where the term "foreman" is used to thcM rules, general order, 
special instructioiu, and Form y example (3) trato orders, k will also 
apply to the employee to charge of work. 

Where switching or work is to be performed, where it b necessary 
to pan the "CONDITIONAL STOP" several times, engineer must 
have an undemanding with foreman to charge of work, at to work 
10 be performed, hmitt, and time his trato or engine may work 
withto these limiu. 

When rcnricted track is lest than two ntilet from terminal or junc- 
tion potot and distance docs not permit "PROCEED PREPARED 
TO STOP" sign to be displayed as required by the rules, sign will be 
displayed at far at possible from "conditional nop" sign but not 
farther than the nrsi switch through which train leaves the terminal 
and not beyond the dearanoe at junction potot . The location of such 
yrilow sign so placed must be designated by trato order. 

S. RULE II: UNATTENDED FUSEE: 
A trato findtog an unattended fusee burning on or near its track 
must stop and afta stopping, train must proceed at restricted speed 
for a safe flagging distance from where fusee was displayed. 

«. RULE 12: TORPEDOES: 

The explosion of oik or more torpedo(es) requires trato to im- 
mediately reduce to restricted speed for a safe flagging distance from 
the potot where exploded. 

7. RULE 93: 3rd paragraph does not apply. 

t. RULE 97(A): Does not apply. 

9. RULE 99: The flagging distance is shown to the station page of 
each lubdivisiOD. 

10. RULE 100: Returning movement must be made at restricied 
speed. 



14 TIMETABLE NO. 2 



81 APPENDIX C 

y ECIAL WiSTWUCnONS 

Howcm. if • Gtf oocupW Ky gttvdi or udiaiol CMSfti b •quip- 
ped with ■ li|ht«d bcUCT or Move, it bus te tLc fourtb ew Wuad 
■ay Gv raquirinc "EXPLOSIVES A" pl»ardt. 

PmMm li Triie ■■« NotfflcalloB to CevdMtpr m4 r-gtiftiT' m 
TMm CoMalBiit Cm rtecwtftd "EXPL06IVIS A" mk/m 
"POISON GAS" 

112. la • nwviag or lundini iraiB. a car alaeardcd "EX- 
PLOSIVES A" or "POISON OAS" aay b« be plaead ntartr Oaa 
the linh ear from the oginc or aa occupied cabooee. However, 
when tiM lenfth of the train will not pennit this ear to be 10 placed, it 
BUA be pUoed ai Bear the niddie of the train at poniMe, but not 
leu than the lecond ear from the cncine or occupied cabotxe. 

Ai each point where trains arc made up or twitched by crewi other 
than the aew which will handle the departing movonent, the con- 
ductor and Engineer must be iuued information showing the loca- 
tion in train of each car placarded "EXPLOSIVES A" or 
"POISON CAS." 

At poiau where crewi arc relieved, the form mutt be trantferred 
to the reUeviag crew. 

Porittoe la Train of Can Plaeardad "KADIOACnVF' 

1 13. la a iDoving or nanding train, a ear placarded "RADIOAC- 
TIVE" may B0( be pUoed oen to any other loaded placarded ear 
(other than one placarded "COMBUSTIBLE") aa ea^, occupied 
cabooK, or carload of oadevdoped fUm. Cui rf«'-y4f»a 
"RADIOACTIVE" may be placed nen to each other. 

ScparatlBg Can Placarded "EXPLOSIVES A" or "POISON 
CAS" From Other Can h Ti^m 

114. (a) la a moving or nanding train, a car placarded "EX- 
PLOSIVES A" or "POISON CAS" mey not be placed oen to: 

I. A putenger car or combination or thai may be occupied ex- 
cept v provided in Rule 1 1 1 . 

2 Any loaded placarded car other than a car placarded with the 
•ame placard or one placarded "COMBUSTIBLE"; 

3. Aa engine: 

4. A loaded flatear. except that loaded can placarded "EX- 
PLOSIVES A" may be placed sen to each other. A (latcar equip- 
ped with permanently attached end* of rigid construction is con- 
sidered to be aa opeit-top car; 

5. Ab opcB-top car when any of the lading protrudes beyond the 
car cBdt or when any of the lading extending above the ar ends is 
liable to shift so as to protrude beyond the car eods; 

i. A cat with automatic tcftigeratioB or heating apparatus \a 
oper a tioB. or a car with open-flame apparatus in service, or with an 
tateraal combustion tofpnt in operation; 

7. A car containing lighted beaten, stovat, or lameru; or 

I. A car occupied by any pcrsoa. Including my attendam for the 
oargo coBiaiitcd thereiB, except as provided ia Riaics 111. 

(b) In a moving or standing train, a ear placarded "EX- 
PLOSIVES A" may aot be placed ant to a car placarded 
"POISON CAS." 

PaiMioa la TraU of Leaded Placarded Taak Car fKka Iksa Cae 
Placarded "OOMBUSmLT* 

115. Except for a tank ear placarded "COMBUSTIBLE", a load- 
ed placarded tank car in a t&oviag or standing train may isoi be 
■carer than the sixth ear from the cagine, occupied cabooee, or 
passenger car . However, when the length of the train wiD doi permit 
a loaded placarded taak car to be so placed, it must be placed as Dear 
the auddle of the train as possible ai>d not Dcartr than the Mooed ear 
from the e&giiie. occupied caboose, or passengv car. 

The Conduewr and EitgiiMer must be furaished information as to 
the locatioa of all placarded can in train. Tkit iaformatioB asay be 
furaished on Train Consist or meutge. 

M TIMETABLE NO. 2 



APPENDIX C 




II 



I: 



^ II I 
1; 



H !1 

n III 

111 



II t I- lis I 

h } ^^ lit t 

If I II Ifl I 

ll i 51 ill I 

f? 2 fi sl? 2 

fi s I? !li I 

iUls if- 5 5? *-'? s : 

SSl 5 5? £«l =1 i 




^ yeO«»U»T»U^ B'\S 



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/ 



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ll: 



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ill 

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ip 

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pi 



83 

APPENDIX D 

CHICAGO, ROCK ISLAND AND PACIFIC RAILROAD COMPANY 
RULES AND INSTRUCTIONS FOR TRAIN HANDLING AND OPERATION OF THE AIR BRAKES 

(EXCERPTS) 



TRAIN AIR TEST 

Rule 1 

NOTE TO INITIAL TERMINAL: 

Where the term initial terminal ia lued 
in these Train Air Test rule*, It refer* 
to that terminal where the train ia ori- 
ginally made np. It may or may not be 
the initial terminal on a rab-dhvialon, aa 
defined in the UNIFORM CODE OF 
OPERATING RULES. 

Rule 2 

CAUTION ; During brake pipe leakage teat, 
with 26 L equipment, after determining the 
•mount of leakage, the engineer must make 
a reduction of equalizing preaaure that will 
equal brake pipe preaaure before cutting in 
the double heading rock. Then eDl*in the 
double heading eock and immediately com* 
plete a full aer^ice brake pipe reduction. 

Rule 3 

§ Train air-brake s>'steni tests. 

(a) Supervisors are jointly responsible vith in- 
spectors, encincmen and trainmen for con- 
dition of air brake and air signal equipment 
on motive power and cars to the extent that 
it is possible to detect defective equipment 
by required air tests. 

(b) Communicatini; signal i>-stem on passenger 
equipment trains must be tested and kno%«-n 
to be in a suiuble condition for aervire be- 
fore leaving terminal. 

1 



Train Air Teste 

(c) Each train must haxT the air brakes in ef- 
fective operating condition, and at no time 
shall the number and location of operative 
air brakes be less than permitted by Federal 
requirements. When piston travel is in ex- 
cess of 10 inches, the air brakes cannot be 
coiuidered in effective operating condition. 

(d) Condensation must be blow-n from the pipe 
from which air u taken before connecting 
yard line or motive power to train. 

INITUL TERMINAL ROAD TRAIN 
AIR BRAKE TESTS 

Rule 4 

(a) Except for run-through and unit run-through 
&ains covered under Rule 10, each train must 
be inspected and tested as specified in this 
section at points — 

1. Where the train is originally made up 
(initial terminal) ; 

2. Where train consist is changed, other than 
by adding or removing a solid block of 
cars, and the train brake S)-stem remains 
charged; and 

3. Where a train is received in interchange. 

(b) Each carrier shall designate additional inspec- 
tion poinu not more than 500 miles apart 
where intermediate iiupection will be made 
to detennine that — 

1. Brake pipe pressure leakage does not exceed 
5 pounds per minute ; 

2. Brakes apply on each car in response to a 
20 pound service brake pipe pressure re- 
duction; and 



APPENDIX D 



84 



TralD Air Teste 

3. Brake rigging if properly secured and does 
not bind or foul. 

(c) Train airbrake system must be charged to 
required air pressure, angle cocks and cutout 
cocks must be properly positioned, air hoie 
must be properly coupled and must be in con- 
dition for service. An examination must be 
made for leaks and necessar>' repairs made to 
reduce leakage to a minimum. Retaining 
valves and reuining valve pipes must be in- 
spected and knouTi to be in condition for 
service. 

(d) (1) After the airbrake s>;stem on a freight 

train is charged to v-ithin 15 pounds of 
the setting of the feed valve on the loco- 
motive, but to not less than 60 pounds, 
as indicated by an accurate gauge at rear 
end of train, and on a passenger train 
when charged to not less than 70 pounds, 
and upon receiving the signal to apply 
brakes for test, a 15 pound brake pipe 
service reduction must be made in auto- 
matic brake operations, the brake vaKc 
lapped, and the number of pounds of 
brake pipe leakage per minute noted as 
indicated by the brake pipe gauge, after 
which brake pipe reduction must be in- 
creased to full service. Inspection of the 
train brakes must be made to determine 
that angle cocks are properly positioned, 
that the brakes are applied on each car, 
that piston travel is correct, and that all 
paru of the brake equipment are properly 
secured. When this insjjection has been 
completed, the release signal must be 
Kiven and brakes released and each brake 
inspected to see that all ha\-e released. 
(2) Omitted intentionally. 



Train Air TmU 

(3) When a locomotive used to haul the train 
is provided nnth a means for maintaining 
brake pipe pressure at a corutant level 
during service application of the train 
brakes, this feature must be cut out dur- 
ing train air brake tests. 

(e) Brake pipe leakage must not exceed 5 pounds 
per minute. 

(f) (1) At initial terminal piston travel of body- 

mounted brake cylinders which is kss 
than 7 inches or more than 9 inches must 
be adjusted to nomirully 7 inches. 

(2) Minimum brake cylinder piston travel of 
truck-mounted brake cylinders must be 
sufficient to provide proper brake shoe 
clearance when brakes arc released. 
Maximum piston travel must not exceed 
6 inches. 

(3) Piston travel of brake cylinders on freight 
cars equipped with other than sundard 
single capacity brake, must be adjusted 
as indicated on badge plate or stenciling 
on car located in a conspicuous place 
near brake cylinder. 

(g) When test of airbrakes has been completed 
the engineman and conductor must be advised 
that train is in projxr condition to proceed. 

(h) During funding test, brakes must not be 
applied or released until proper signal u gi\-en. 

(i) (1) When train airbrake system b tested from 
a yard test plant, an engineer's brake valve 
or a fuiuble test device must be used to 
provide increase and reduction of brake 
pipe air pressure at the tame or a slower 
rate as with en^neer'f brake valve and 



85 



APPENDIX D 



Train Air TcsU 

yard test plant must be connected to the 
end which will be nearest to the hauling 
road locomotive. 

(2) When yard test plant is used, the train 
airbrakes system must be charged and 
tested as prescribed by paragraphs (c) to 
(g) of this section inclusive, and when 
practicable should be kept charged until 
road motive power is coupled to train, 
after which, an automatic brake applica- 
tion and release test of airbrakes on rear 
car must be made. 

(3) If after testing the brakes as prescribed 
in subparagraph (2) of this paragraph 
the train b not kept charged until road 
motive power is attached, the brakes must 
be tested as prescribed by paragraph (d) 
( 1 ) of this section. 

(j) Before adjusting piston travel or working on 
brake rigging, cutout cock in brake pipe 
branch must be closed and air rvservoirs must 
be drained. When cutout cocks are provided 
in brake c>linder pipes, these cutout cocks only 
may be closed and air reserxoin need not be 
drained. 



ROAD TRAIN AND INTERMEDIATE 
TERMINAL TRAIN AIR BRAKE TESTS 

Rule 5 

(a) Passenger trains : Before motive power is de- 
tached or angle cocks are closed on a pas- 
senger train operated in either automatic 
or electro-pneumatic brake operation, t# 
cept when closing angle cocks for cutting 
off one or more can from the rear end of 



Train Air TcaU 

train, autcnnatic air brake must be applied. 
After recoupling, brake i>-stem must be re- 
charged to required air pressure and before 
proceeding and upon receipt of proper re- 
quest or signal, application and release tests 
of brakes on rear car must be made from 
locomotix-e in automatic brake operation. 
Inspector or trainmen must determine if 
brakes on rear car of train properly apply 
and release. 

(b) Freight trains: Before motive povk-er is de- 
Uched or angle cocks are closed on a freight 
train, brakes" must be applied with not less 
than a 20 pound brake pipe reduction. 
After recouplinc and angle cocks are 
opened, it must be known &at brake pipe 
air pressure is being properly restored as 
indicated by the caboose gauge and that 
brakes on rear car are released. In the ab- 
sence of a caboose gauge, air brake test 
must be made as prescribed by that portion 
of paragraph (a) of this section peruining 
to automatic brake operation. 

(c) (1) At a point other than initial terminal 

where locomotive or caboose is 
changed, or where one or more con- 
secutive can are cut off from rear end 
or head end of train %*ith consist other- 
wise remaining intact, after train brake 
system is charged to within 15 pounds 
of feed valve setting on locomotive but 
not less than 60 pounds as indicated 
at rear of freight train, and on a pas- 
senger train to at least 70 pounds, a 
20-pound brake pipe reduction must 
be made and it must be determined 
that brakes on rear car apply and re- 
lease properly. 



APPENDIX D 



86 



Train Air TctU Train Air Tcsu 



(2) Before proceeding it must be known 
that brake pipe pressure as indicated 
at rear of freight train is being restored 

(d) (1) At .a point other than a terminal 
where one or more cars are added to a 
train, and after the train brake system 
is charged to not less than 60 pounds 
as indicated by a gauge at the rear of 
freight train and on a passenger train 
to not less than 70 pounds, tests of air 
brakes must be made to determine that 
brake pipe leakage does not exceed 
five (5) pounds per minute as indi- 
cated in the brake pipe gauge after 
a 15 pound brake pipe reduction. 
After the leakage test is completed, 
brake pipe reduction must be increaised 
to full service, and it must be known 
that the brakes on each of these cars 
and on the rear car of train apply and 
release. Cars added to train which 
have not been inspected in accordance 
with § Rule 4 (c) to (j) must be to 
inspected and tested at next terminal 
where facilities are available for such 
attention. 

(2) (i) at a terminal where a solid block 
of cars which has been previously 
charged and tested as prescrilwd 
by S Rule 4 (c) to (j) is added 
to a train, test must be made to 
determine that brakes on the rear 
car of train apply and release. 

(ii) When cars which have not been 
prexiously charged and tested as 
prescribed by { Rule 4 (c) to (j) 
are added to a train, tuch cars 



may either be gixxn iiupection and 
tests in accordance %vith § Rule 4 
(c) to (j), or tested as prescribed 
b)- subparagraph ( 1 ) of this para- 
graph prior to departure in which 
case these cars must be inspected 
and tested in accordance with 
S Rule 4 (c) to (}) at next termi- 
nal. 

(3) Before proceeding it must be known 
that the brake pipe pressure at the 
rear of freight train is being restored. 

(e) (1) Transfer train and >-ard train move- 

menU not exceeding 20 miles, must 
have the air brake hose coupled be- 
tween all cars, and after the brake 
t><stem is charged to not less than 60 
pounds, a 15 pound service brake pipe 
reduction must be made to determine 
that the brakes are applied on each 
car before releasing and proceeding. 
(2) Transfer train and yard train move- 
ment exceeding 20 miles must have 
brake inspection in accordance with 
8 Rule 4 (c) to (j). 

(f) The automatic air brake must not be de- 
pended upon to hold a locomoti\-e, cars or 
train, when sttnding on a grade, whether 
locomotive is atuched or detached from 
can or train, \^'hen required, a sufficient 
number of hand brakes must be applied to 
hold train, before air brakes are released. 
When ready to sun, hand brakes must not 
be fcleased until it is known that the air 
brake system is properly charged. 






87 
APPENDIX E 
49 CFR PART 217 (EXCERPTS) 



»^dg^ tallrMd AdalnbtroHMi, DOT 

_^Miaoer mutt wbinlt • written re- 
SSitot » beuinf within tUteen (18) 
J?, gfter the oonferenoe. The bear- 
Si wOl oommenoe within fourteen 
Ju) e»len<l*r (Uyi of receipt of the re- 
^ILi And viU be conducted In ftcoord- 
J^wlth weUoni ii€ utd 6?5. TiUe 6. 

^u) Unl«> stayed or modified by the 
*]Linii tT»tor. the requlremenU of 
^h Bnergency Order iMued under 
rttumbpart ihall remain In effect and 
llf^teerved pending dedtlon on a petl- 
Hbo for review. 
|gli.S7 BctcrtattoA at aotbority and iia- 



IHe FRA may taue Emenency 
Afden conMmlnf track without 
ffnri to the procedures prescribed In 
tbii subpart whenever the Admlnlstra- 
lor determines that immediate action 
h lequlied to assure the public safety. 

f AIT 217— lAILiOAO 0KKATIN6 
lULES 



IITJ Puipote. 

U7J AppUcaUon. 

tlTJ Penalty. 

tl7.l FUlnt of operating ruin. 

niJ ProfraiB of operational UsU and tn- 

veeUons: rccordkeeplns. 
tXI.U Proffram of InstructloD oo T'^'Hg 

ralM. 
tl1.1l Aanuti report. 
tl1.1i Inf onnatloD eoUacUon. 
Mrrana A— 6cbdcli or Civn. Pnusxas 

Avnotrrr Sect. W3 and M9. M SUt. t71 
iBd m <«8 V£.C. 4>1 and 4M). and sec. 
LOta) of the rcfulaUoni of the Offiee of 
tte Secretary of Transportation. 4* CfSt 
LO(B). 

•oncK IS nt 411M, Mov. U. ir»C nataM 
stbcrvlM noted. 

tv^pmrt A—0»»9tm\ 

imj ra^oac. 

Through the requlremenU of this 
psrt the Federal Railroad Administra- 
tion learns the condition of operating 
nUes and prmcUoes with respect to 
mint and other rolling equipment In 
the railroad industry, and each rail- 
>Md is required to Instruct Its employ- 
es' In operating practices. 



• t17.f 

• S17J ApfllcayeB. 

<a) Except as provided In paragraph 
(b) of this section, this part applies to 
railroads that operate trains or other 
rolling equipment on standard gage 
track which is part of the general rail- 
road system of transportation. 

(b) This part does not apply to— 

(1) A railroad that operates only on 
track iitside an Installation which Is 
not part of the general railroad system 
of transportation; or 

(2) A rapid transit railroad that op- 
erates only OD track used exclusively 
for rapid transit, commuter, or ether 
ihort>hau] passenger servloe In a met- 
ropolitan or suburban area. 

C40 nt MM. Jan. U. WW 

1 217 J PWahy. 

Bach railroad to which this part ap- 
plies that violates any requirement 
prescribed In this part Is liable to a 
dvll penalty of at least $250 but not 
more than 12500. 

• 217.7 rUiMefeyefaUngnlca. 

(a) Before February 1. 1975. aaeh 
railroad that Is In operation on Janu- 
ary 1. 1975. shall fUe with the Federal 
Railroad Administrator. Washington. 
D.C. 20590, one copy of tts code of ep- 
•rating rules, timetables, and timeta- 
ble spedal Instructions which were In 
•ffeet OD January 1. 1976. Bach raO- 
road that eommenoes operation after 
January 1. 1975, shall fOe with the Ad- 
ministrator one eopy of Its eode of op- 
erating rules, timetables, and timeta- 
ble Instructions before tt oommenees 
operations. 

(b) Each amendment to a railroad's 
eode of operating rules, each new 
timetable, and each new tIMtetable fe- 
cial Instruction which Is issued after 
January 1. 1975, shall be filed with the 
Federal Railroad Administrator within 
M days after it Is Issued. 

I217J Prograa eT opcratioiial taato a^ 
laspcetlens: reeordkeeyiag. 

(a) Each railroad to which this part 
applies s^all periodically eonduet 
^wratlonal tests and Inspections to 
determine the extent of ec»npllanee 
with Its eode of operating rules, time- 
tables, and timetables spedal Instnie- 



APPENDIX E 



88 



1117.11 

tioiu In wcorcUnce with • procrsm 
fUed with the Federm] lUUnwd Ad- 
mixklstrator. 

(b) Before March 1. 1975. or M dayi 
before eommenclns operations, whl^- 
tver is Uter. each railroad to whkh 
this part appUes shall file with the 
Federal RaUroad Administrator. 
Washlnfton. D.C. S06M). three copies 
of a program for periodic conduct of 
the operational tesu and inspections 
required by paracraph <a) of this sec- 
tion. The protram shall— 

(1) Provide for operational testing 
and Inspection under the various oper- 
ating conditions on the railroad: 

(2) Describe each type of operational 
test and Inspection adopted, including 
the means and procedures used to 
carry It out: 

(3) Bute the purpose of each type of 
operational test and inspection: 

(4) State, according to operating di- 
visions where applicable, the frequen- 
cy with which each tyi>e of operation- 
al test and inspection is conducted: 

(5) Begin within SO days after it is 
fUed with the Federal Railroad Ad- 
ministrator, and 

(6) Include a schedule for making 
the program fully operative within 210 
days after It begins. 

(c) Each amendment to a raOroad's 
program for periodic conduct of oper- 
ational tests and inspections raqulred 
under paragraph (a) of this aeetion 
shall be fUed with the Federal Rail- 
road Administrator within M days 
after it is issued. 

(d) Recordt. Each railroad shall keep 
a record of the date and place of each 
operatioital test and inspection per- 
formed in accordance with its pro- 
gram. Each record must provide a 
brief description of the operational 
test or Inspection, including the char- 
acterisUcs of the operation tested or 
inspected, and the results thereof. 
Records must be retained for one year 
and made available to representatives 
of the Federal Railroad Administra- 
tion for inspection and copying during 
regular business hours. 

• 217.11 Progrmm oriMtniction M eftiat- 
lag ralM. 

(a) To ensure that each raOroad em- 
ployee whose activities are governed 
by the railroad's operating rules un- 



4f CHt Oi. ■ (10.14* Mtiaa) 

tferstands those rules, each railroad to 
which this part applies shall pertodt. 
eaUy Instruct that employee on the 
meaning and application of the ran. 
road's operating rules in accordaoet 
with a program flled with the Fedetvi 
Railroad Administrator. 

(b) Before ICareh 1. 1975 or SO dayi 
before commencing oper«tlons, which- 
ever Is later, each railroad shall fUe 
with the Federal RaUroad Admlnlstra. 
tor. Washington. D.C. S0590. thite 
copies of a program for the periodic 
instruction of Its employees as i«. 
quired by paragraph (a) of this sec- 
tion. This program shall— 

O) Describe the means and ^oce- 
dures used for instruction of the vari- 
ous classes of affected employees; 

(2) State the frequency of Instruc- 
tion and the basis for detemlning 
that f rcquener. 

(S) Include a schedule for complet- 
ing the Initial instruction of employea 
who are already employed when the 
program begins: 

(4) Begin within SO days after tt k 
filed with the Federal Railroad Ad- 
ministrator. 

(5> Provide for initial Instruction of 
each employee hired after the pro- 
■ram b eg i n s, 

(c) Bach amendment to a railroad's 
program for the periodic instruction of 
tts employees required under para- 
graph (a) of this section shall be fUed 
with the Federal Railroad Administra- 
tor within SO days after it is issued. 

• 21T.1S Aanaal report. 

Before March 1 of each year, oada 
raOroad to which this part applies, 
except for a railroad with fewer than 
400.000 total manhoura. ihall file with 
the Federal Railroad Administrator. 
Washington. D.C. 20590, a written 
report of the following with respect to 
tts previous year's aetlvltiea. 

(a) The total number of train mOas 
which were optr^eA over Its track. 

(b) A tammuTot the number, type. 
and result of each operational test and 
Inspection, stated according to operat- 
ing divisions where applicable, that 
was conducted as required by 1 217 J. 

(e) The number of opeimtional tests 
and inspections conducted as required 
by 1 217.9 per 10.000 train mUes. 




89 

APPENDIX F 

SAFETY BOARD LETTER DATED DECEMBER 7, 1988, and 
FRA LETTER DATED JANUARY 18, 1989 



National Transportation Safety Board 

WMhingten, D.C. 206M 
Deceaber 7. 1988 



Mr. Joseph U. Halsh 

Associate Adalnlstrator for Safety 

Federal Railroad Adnlnlstratlon 

Room 8320A 

400 7th Street 

Washington. D.C. 20590 

Dear Mr. WaUh: 

Re: Head-On Collision Between Iowa Interstate Railroad Ltd. 

Extra 470 Uest and Extra 406 East with Release of Hazardous 
Material Near Altoona, Iowa, July 30. 1988 - DCA 88-MR-006 

During the Investigation of the above referenced accident 
the Safety Board was Informed by the Iowa Interstate Railroad 
(lAIS) officers that they did not perforn operational tests and 
Inspections for various reasons: 1) 'When the Iowa Interstate 
L.T.D. applied with the I.C.C, we did not Indicate we would do 
operational testing."; 2) had waivers from the Interstate 
Commerce Commission (ICC) and Federal Railroad Administration 
(FRA) for not performing Operational Tests; 3) "...has 
historically been exempt from 49 CFR Part 217.9 pursant to 
Part 217.13." One operating officer had stated that the lAIS had 
filed In accordance with 49 CFR Part 217 while another operating 
officer stated that the lAIS had not filed. However, the lAIS 
could not provide documentation for an exemption or waiver. 

On September 7. 1988. the Investigator. 1n-Charge. E. B. 
Dobranetskl. met with FRA headquarters personnel from the 
Operations Practice Division to ascertain the lAIS status with 
49 CFR Part 217 and was Informed: 1) the carrier had no rule book 
on file; 2) the carrier had no operating procedure and Inspection 
plan on file; and 3) the carrier had reported over 400,000 
manhours for 1987. 

Also, the Safety Board had reviewed Information from the FRA 
System Support Division showing that on September 2. 1987. while 
at Blue Island. IL. an FRA Inspector filed an exception to 49 CFR 
Part 217.9, with the remark that he had discussed operational 
testing with (unnamed) company officials and that the railroad 
does not periodically conduct operational tests and Inspections 
to determine the. extent of the compliance with Its code of 
operating rules, timetable and timetable special instructions. 
Furthermore, FRA Chief Counsel's office reported no record of a 
violation filed and; the lAIS claimed no knowledge of this 
exception report. 



APPENDIX F 90 



- 2 - 

The Safety Board would appreciate the Federal Railroad 
Adalnlstratlon's response to the follovlng: 

Has the Iowa Interstate Railroad granted an cxeaptlon 
or waiver fro* the provisions of 49 CFR Part 217?; 
When? 

Is the Iowa Interstate Railroad In. coapllancc with 49 
CFR Part 217? 

Has the Iowa Interstate Railroad petitioned for an 
exenptlon froa 49 CFR Part 2177; Hhen? 

Has the Iowa Interstate Railroad filed as required by 
49 CFR Part 217.77 

Has the Iowa Interstate Railroad aet the provisions of 
49 CFR Part 217.97 

Has the Iowa Interstate Railroad aet the provisions of 
49 CFR Part 217.11? 

Has the Iowa Interstate Railroad aet the provisions of 
49 CFR Part 217.13? 

How was the exception to 49 CFR Part 217.9 that was 
filed on September 9, 1987, resolved? 

What actions. If any, are being conteaplated by the 
FRA to assure compliance by this and other regional 
rail carriers with 49 CFR 217 and other ainlaun safety 
regulations. 

The Safety Board looks forward to a response froa the 
Federal Railroad Administration with respect to the above 
concerning the Iowa Interstate Railroad and 49 CFR 217. If you 
have any questions regarding the above, please contact ae at 
(202) 382-6840. 

Sincerely, 



Winiaa G. Zitllnski 

Chief 

Railroad Accident Division 



91 APPENDIX F 



o 



USOeponmert 
of tonsponoftion 

Ft4«rat RoUrood 
AdmlnUtraHon 



Mr. William G. Zielinslii 
Chief, Jtailroad Accident Division 
National Transportation Safety Board 
800 Independence Avenue, S.W. 
Washington, D.C. 20594 

Dear Mr. Zielinski: 

Thank you for your recent letter requesting infomation about the 
Iowa Ijiterstate Railroad Limited (lAIS). 

The questions set forth in your letter are responded to in the 
order in which they were written. 

o Was the lAIS granted an exemption pr waiver 
from the provisions of 49 CFR Part 217? 

When? 

Response: No 

o Is the lAIS in compliance with 49 CFR Part 
2177 

Response: No 

o Has the lAIS petitioned for an exemption from 
49 CFR 217? 

Response: No 

o Has the lAIS filed as required by 49 CFR Part 

217.7? 

Response: Yes^ 

o Has the lAIS met the provisions of 49 CFR 
Part 217.9? 

Response: The lAIS, in December 1988, filed 
a program of operational tests and 
inspections with the FRA's Washington, D.C, 
Office of Safety. 



APPENDIX F 92 



o Has the lAIS met the provisions of 49 CFR 
217. XI? 

Response: No 

o Has the lAIS met the provisions of 49. CFR 
Part 217.13? 

Response: The lAIS, because more then 
400,000 total nanhours were worKed by their 
employees in the calendar year 1987, was 
required to file a report for that period. 
That report was filed but not in a timely 
manner. 

o How was the exception to 49 CFR Part 217.9 
that was filed on September 9, 1987, 
resolved? 

Response: Carrier officials were admonished 
to bring the lAIS programs required under 49 
CFR 217 into compliance. 

o What actions, if any, are being contemplated 
by the Federal Railroad Administration to 
assure compliance by this and other regional 
rail carriers with 49 CFR 217 and other 
minimum safety regulations? 

Response: The FRA has initiated an enforce- 
ment action against the lAIS through the 
procedures of the Federal Claims Collection Act. 

Also, the FRA will continue to monitor, provide guidance, and 
initiate enforcement, if necessary, to achieve compliance with 
Title 49 CFR 217 and other safety regulations. 

Sincerely, 

J. H. Walsh 

Associate Administrator 
for Safety 



93 
APPENDIX G 
NATIONAL TRANSPORTATION SAFETY BOARD ACCIDENT REPORTING CRITERIA 



r.d.f.1 R„i.,., / Vol. 53. No. 234 / T»„diy. December 6. 198a / Rule, wd »>«.l...«,. 



«>1S1 



yAFETV BOARD 

•Unct: NatteiMl TVutpeitatlaa fefiiy 
iFiMlnile. 



fMMAm ^ Ihte nilt dtMM. At levd 
to UMadim I MM to rtduce Ifa* Mitod 
of tifflt durim «dtlch aetUteatiaa of 
cwttiD nUrMd •eddtau t« mudtton 
to 2 boun afltr the oeoimoe* ef u 
•ceidtat thai muhi b • bttlitr ar 
wrioM bilHiy to iwe cr Bon 
otwDcfflbcri er paiicaMn. ibt 
imericagr evtcuitjoB cJt p«ucii|cr 
train, or Ib« rcleiu of bixwdetM 
Mttriilt. ■• furlfctr de toilwd bmla: 
and to 4 boun for aay aeddtot Ibat 
itquirti aa avaluattoB ef property 
dafflafe. 

vraenvi oati; Pabruary i^ imk 
M« nmTMui MFMiuTiOM contact: 
Mr. William C. ZicIintU Chief. Railroad 
Acddcnl Divlaion. HO iDdepcndcooe 
Avenue. 8W., Waahinftoo. DC WM 
((102))SI-a640). 

•wrnXMINTAinr MTMHATW* StCtioO 

•404 reouirt* Dottfleattoa to the 
Nattonal Trtuportaboa Safely Board of 
certain railroad, and, isclBdcd tberela. 
nil rapid Iranail aeddcott. at Oe 
aarliast pnetieal tine. Ibe SafeW 
Board't rulet thai pertain to •eliBcaltoa 
of radroad acddenU, apedficaOy Rale 
MOJ, provide a eeaveaieni Btechaalaa 
for eeaplylni with the notiflcalioa 
tequiremeni to the fons of e toll-frae 
telephone aomber, and, prior to Ihia 
aaicndmenL Ihow Rulee Inpoecd a itx- 
hour time Umlt durini which raportint 
wae mandatory. NolwilhatandJM the 
toll-free tetepbone aumbcr andtoe ttit- 
hour Ume hmil the Safely Board 
delemiaed that there wen ttill 
Dumeroui Inalanoce when npeitiai of 
tcddenti wai not auRIdeal^ 
tzpediUoua aa to afford Beard pereeoad 
•eceaa to the aeddeol tile hefon Am 
Initiation of petl-aeddeai deanap 
afforta. b order to naedy the ailuafloa 
and after aetiee and public procedan 
(8S n 11$20t pubUihed April 7. tW], 
the Board ia aaendint It* nllread 
aeddent aetUlcatien tuttt to loquin 
Boiificatioa withla two heun of any 
ntlroad aeddent thai iavolvea a 
tataliiy. to|ury dut require* admiaaias 
to a hoepltal of two or man 
GKwmcmberi or patMaitra. the relcue 
•f hetardeui material!, or an emcrfcncy 
tvacuab'on. In cam thai do aol tovolve 
•ny of Ihetc eveniualltiet but that 



APPENDIX G 



94 



4I1SS r«derij RejiitM / Vol. 53. No- 04 / Tu«tdey. Decewbtr 6. 19M / Rulei tnd Rerilitiotu 



rcquirt t prtlimlnaty anotUiy ntimtti 
oldtm»t*t. • four-hour Boilt )• Wng 
plac*d oe dM acliflcatioa Iibm. 

AddftioMlly. (Ithouik vtrtuDy all 
railroad Iraia* and radlilia* an «l 
prcuni aquipptd for radio 
comnuinlcation. thi Beard raca(aiiaa 
Oial In eailain ntraordinary 
drcunulancaa. communicalion from tha 
aiia of an aecJdtni tmowditttly ifltr It* 
oecurTtitcc aiay b« f robltfliiticaL TUa 
eeJd b* tfet cait io accideau ocoirriAi 
la rtmeta ana* wban ndio 
tranimiiileti ii ioiffidiva. to wuA 
iMtaocM Oi« nportini In* limiu 
pntciibti In 1 840J[al eas b« eesoutcd 
from th* tiOM nSroad p*rtocncL ethar 
than thoi* *l lh« *ccidf nl ill* at th* 
liffl* of ill oecumnca, hiv* nc(lv*d 
notic* of th* iccidtoL Thi* pr«>{(ioa i* 
esniaintd in H'a<'apb (d] «f Ilia 
nviMd ragulitioD. 

Th* Safety Board neiivid Bv* 
eommcnu In ntpona* to It* aotica of 
propoud rul*m*kin| which wai 
pubtiihcd April T. 19M (U T* I1S»). 
The Board h*i flvn tht vtcwi 
axpntMd ki ibo** rtfpcniti It* canfal 
eonaidcratlea b«t findi that our 
axpnaiad |d*J af atTofdint Beaad 
panonntl auei* to th* *oc>d«nt ail* a* 
*arly a* po**ibl*, and »-hcrcvar 
ftaiiblc. btfon iaitiaticn of ekao-ap 
affena, I* paraaiouat and that tha 
dtlatariou* *ff*cl* of *arll*r nportinf 
may in lact M«*f matarialiaa. 

n* aalor ob«tael* to Iba 
raqonfflcNlj for tarliar rtporttnf 
coaccm* tb* dilTiculty of anivlni at a 
pnliminary atonalaiy aatvnal* ^ 
damafa. Oim eoffia*nl*iar *xpr***ad 
eoncara Ikat *ecJd«Bb that do aoi B*at 
th* Board'a aatinalaJ damaj* erS<*ria 
waald ba neonad bocauM of batty 
daatf* *vala*tia«. T^ io a rd 
eonudarad lb«t po*«ibikiy wfaao M 
propotad a 4-hour Uwt (or aaj aocidal 
nquiruii a damap aaliaala. Manevar, 
th* Board do«« Ml baliava tat tba 
f«per«ia| of any accidanu tfcil do Ml 
osaat thot* aniaria will impoaa as aftdua 
adainitlraHv* bwdaa oa alhar te 
rcportnt railroad or an Iba Maty 
Beard'* alaS. 

la nipael lo Ih* eanaael iKat 
InilMiioa of cl*an-up cOoru *bouJd laka 
prroadcao* ov*r all a;b*r ac^TWtit Iha 



Board b(U«v« that Ih* aecidafil ear* 
and pravantton ob)*cti«*« that an Itt 
feivaaUiaien goal an a^oally aaatnlUl 
it k paiMi mat a aaaibar of taika, aack 
a* tba prapai eontrol «f hauidea* 
■akriat*. araat W andariaUa at aw« 
how(*ar. MtlflcaOoii to ttta Board at fta 
avBaai pracdcabk Hna aflar fta 
eeewnnca k aqaaBy k t* bart 
bitantu efpubUc aafaiy and aeddaal 
prtvantioa. and H k toparativa that tba 
Board b* Mtifttd a* *oen at po«*ibla if 
baxardeaa aaWilal* an towhid 

At do oibar aftndt* of Ce«*RiMal, 
tb* Oepai«B*nt of Tiaetportatioa'a 
R*t*arch and Spcdal fnfttm* 
Aiminutoitloa aaqain* insiadiak 
nponiai of aiaat biiardota satarkk 
apOl* by aay eanriar tkal kaaapeilt 
than (49 Cni 171.15): aceardin^y. 
■otificaGon to tha Board ihtwiA Iba 
Rational Ratpon** Cantar'i kkplaM 
tarvlea k Ml an ad^Uioaa]'bw4a& All 
ethar mattan daah wUb la te 
coougadtt. ttpadaOy allciBatiM 

EropoMlt. b«v* b**a |lv* eea«ld*nllOB 
y vie DDCrt> 

Und*r 0N erltcrla af tacUoa «n(b1 af 
Iba Rifulatoiy ntxMtt* Act. IU.S.C 
a05(b), th* Safaty Board bu dctaiminad 
that th«t* am(ndm*ot* will not bava a 
aitnificint a t crw a ric te\pae< ob a 
aBbtttntial Bunbar of »m] antilk* 
bacaot* th* d*« ralaa raqam a«ly i 
tomcwhat aion txpaditieut nporta^ 
and (bay do mi oaatt aay iacnaaa \m 
tba auaibar of aecMaek fc» wkIA 
nMfkaHan aaal ba ra4i. Am eerti af 
aontplyiat wtib tba nd* an Ml 
tjbuao^ nd ** Safacy Beard bat aa 
cartiAatf. 
Lki af Sub)a(A te U Cri rait Mi 

AdUnianb** pracHoa aad 
praeadun. lnv**ci|atiaB. Ika a r d i* 
Btalanalt ttantpertaUon. Railroad 
Baftty. Rcpoitiai tnd racorAicapiaf 
nquiniaaatt. 

rAflTB40-{AHCN0CD] 

1. Aeeordi^i. tha aalbort^ eitadD* 
for 4S CfHran MO oonliatfa* la mad aa 
feOewa: 

Mka«y! a*c BKtrNO. M<P*»*«I 
(tf<D Baud AS •( nr< *• aimda4 (*• 

UACiaai». 



1 Saeltaa Mat af Hrf Ma Ckaptar 
Via TMa «L Cod* af fadanl 
Rapubtiaaa. k itvkad to Had u 
Mews 
IMOJ NoOfkaltonafrakaatfaccMaMto. 

na opantor af a nflread diaU aaMfy 
dta Board by tokphanki Iba Nattonal 
RatpoDta Cantar at ttla^Msa nO-U4- 
tan at th* (ariiaat praetlcab]* Una afiai 
Iha eccunanca of aay aw af Iba 
Mowtoir^lread aoddaM: 

(a) Na ki« tba t boun aAar w 
acddaat wblcb naiilu to: 

(1) A fmiofu or oiptoyaa faulty 
or aartoo* ta^uy u two « lacra 
cmrmadbn or paa*««an (aqalriat 
adaiJaiioo to a hoapiul: 

(2) 1%* avaeuaaon af a paat«|ar 
katK 

P) Oaaaft to a lanl car « aeniatoar 
■aolttM ta Nkaaa tf baxarAoM 
BatariaU or lavolvini *«««iiSan af te 
lanara] e<^Uc or 

(4) A btalliy at a rada sotatof. 

|b) No kkr than 4 beun aflar aa 
aeddtai wbicb daat Ml latolv* aay al 
Iba dicuBitaactt aouaaalad ia 
panfrapb (a] of Ihli taatieB Vd wbid 
naulkia: 

(1) Oasai* Ibatfd ee a praUsiaaiy 
gteu attiotala) of tlW.OOO or man for 
npain. or tba eumnt i«p1acaffiaat coat 
to nllraad aad aoonilroad proparV- ar 

(2) Daoiti* of 125,000 or sen to a 
pattaafartvtn vti rdOraad aad 
aeonflroad propafiy. 

(C) Aeddank lavotolBi (otai 
apartSont BaM ba r^oritd Vy ^ 
raSread that eontroli fta »ac]i and 
dirack tb* ■ov*a*ni of ffais* wbata 
tba acddaat bat eeeuirad. 

(d) Whan B aacldanl fcr wbteh 
Mtiflcalioe k raquind by partfnpb (a) 
a* W af Ibk taatka aoeurt k a nBato 
ana. tha tia* Ualu —* ferlb ta that 
paraftopb tbil ea«ui«M« froa Ih* Om* 
Iba Rni nilioad anployaa wbo wa* mi 
atibaacdd(al*(toai**«B*afito 
eecwnnca ba* neaivad Mtic* tb*>«eL 

t^Md at WtAtafKo. DC aa Nevtkte 



llMtLI 

Actini fl ii ai aa 

[PI Doc •««« nM U-Mft »« BO) 



95 
APPENDIX H 
FEDERAL RAILROAD ADMINISTRATION ACCIDENT REPORTING CRITERIA 



PAIT 225— KAILtOAD ACCIDENTS/ 
INODENTS: REPORTS CLASSIFICA- 
TION, AND INVESTIGATIONS 

See. 

XU.l PurpoM. 

3as.3 AppUcsMUty. 

Sec 

aat.l DennlUona. 

S3S.7 PuMte txamlnattoB and uae of iv- 

ns.9 Telephonk report! of certain Md- 
denU/lDcMenta. 

ns.ll Reportinc of aocidents/lncidenta. 

ns.l9 Late report*. 

a3S.lt AcctdenU/inddenta Dot to be re- 
ported. 

338.17 Doubtful eaaea. 

339.11 Primary troupe of acddenta/lnd- 
denta. 

33S.31 Ponna. 

335.33 Joint operationa. 

335.39 Recordkeeplnc. 

335.37 Retention of recorda. 

335.39 PenalUea. 

339.31 Inveatltatlona. 

Arrareix A— Paocoxru roa DRBuamiio 
RspoRTmo TRaaanoLO 

AmEmix B— 8CRXD0U or Crm. PmaLnaa 

ArrHoarrr Seea. 13 and 90, 34 8Ut 383. 
3M. aa amended (49 U.S.C. 13 and 30); aeca. 
1-7. 35 SUt. 350. aa amended, (45 U.8.C. 38- 
43): tea. 203. 308 and 309. 84 SUt 971 and 
975. (45 U.S.C. 431, 437 and 438); leca. e<e) 
and (f ): 80 SUt. 939. (49 U.S.C. ie55<e) and 
ttn. 49 CFR 1.49(b)(ll). (h) and (n); aeca. 
5(b) and (m). 80 SUt 935, (49 U.S.C. 1854(b) 
and (m)); 14 CPR 400.43(c)). 

Sotmcc 39 PR 43224. Dec 11. 1974. unleaa 
othervlae noted. 

EanoauL Notk Por an InterpreUtion of 
Part 335 aee 40 PR 5388. Peb. 5. 1975. 



im.1 

The purpose of this part is to pro- 
vide the Federal Railroad Administrm- 
tlon (FRA) with information concern- 
ing hazardous conditions on the Na- 
tion's railroads. FRA needs this infor- 
mation to carry out effectively Its reg- 
ulatory responsibilities under the Fed- 
eral Railroad Safety Act of 1970 and 
the Accidents Reports Act Although 
this part is issued under the authority 
of both Acts, reliance Is primarily 
based upon the authority of the Fed- 
eral Railroad Safety Act because of its 
broader scope. Issuance of these regu- 
lations under the Federal Railroad 
Safety Act preempts States from pre- 
scribing accident/incident reporting 
requirements. Reliance on the Federal 
Railroad Safety Act will facUIUte the 
application and enforcement of the re- 
quirements of this part by aUowlng 
Imposition of dvU rather than crimi- 
nal penalties. Any State may, however, 
require railroads to submit to it copies 
of accident/incident reports filed with 



FRA under this put. for aeddents/iii. 
eldenU which occur in that Bute. The 
reporting and recordkeeping requlre- 
menta prescribed in this part have 
been approved by the Office of Man- 
agement and Budget in aoeordanee 
with the Federal Reports Act of li)42. 

• tttJ AwllcaUltty. 

This part applies to aU railroads 
except those railroads whose entire 
operations »n confined within an in- 
dustrial installation. 

tttU DeflBltloM. 
As used in this part— 

(a) "Railroad" means any system of 
surface transportation of persons or 
property over rails. It includes line- 
haul freight and passenger railroads, 
switching and terminal raUroads. and 
passenger-carrying railroads including, 
but not limited to, rapid transit, com- 
muter, scenic, subway, elevated, cable, 
and cog railways. 

(b) "Accident/Incident" means: 

(1) Any impact between railroad on- 
traclt equipment and an automobile, 
bus, truck, motorcycle, bicycle, farm 
vehicle or pedestrian at a rail-highway 
grade croeslnr, 

(2) Any collision, derailment, fire, 
explosion, act of God. or other event 
involving operation of railroad on- 
track equipment (standing or moving) 
that results in more than $4,500 in 
damages to railroad on-track equip- 
ment, signals, track, track structures, 
and roadbed: 

(3) Any event arising frtm the optr- 
atlon of a railroad which results in: 

(1) Death of one or more persons; 

(ii) Injury to one or more persona, 
other than railroad employees, that 
requires medical treatment; 

(ill) Injury to one or more employees 
that requires medical treatment or re- 
sults in restriction of worii or motion 
for one or more days, one or more lost 
work days, transfer to another Job, 
termination of employment, or Iom of 
consciousness: or 

(Iv) Occupational illneis of a railroad 
employee as diagnosed by a physician. 

(c) "Joint operations" means rail op- 
erations conducted on a track used 
Jointly or in common by two or more 
railroatto subject to this part or oper- 



APPENDIX H 



96 



atlon of a train, looomotlve. ear or 
other on-track equipment by one rail- 
road over the track of another raU- 
road. 

(d) "Occupational Ulneas" means any 
abnormal condition or disorder of a 
railroad employee, other than one re- 
sulting from Injury, caused by environ- 
mental factors associated with his or 
her railroad employment. Including, 
but hot limited to. acute or chronic Ill- 
nesses or diseases which may be 
caused by inhalation, absorption. In- 
gestion or direct contact. 

(e) "Medical treatment" means 
treatment administered by a physician 
or by registered professional personnel 
under the standing orders of a physi- 
cian. Medical treatment does not In- 
clude first aid treatment (one-time 
treatment), precautionary measures 
such as tetanus shots, and subsequent 
observation of minor scratches, cuts, 
bruises or splinters which do not re- 
quire medical care, even though these 
services are performed by a physician 
or registered professional personneL 

(f) "Lost workdays" means any full 
day or part of a day (consecutive or 
not) other than the day of Injury, that 
a railroad employee is away from work 
because of Injury or occupational ill- 
ness. 

(g) "Restriction of work or motion" 
means the Inability of a railroad em- 
ployee to perform all normally as- 
signed duties because of injury or oc- 
cupational illness, and includes the as- 
signment of a railroad employee to an- 
other Job or to less than full time 
work at a temporary or permanent 
Job. 

(h) "Rail-highway grade crossing" 
means a location where one or more 
railroad tracks cross a public highway, 
road, or street or a private roadway, 
and includes sidewalks and pathways 
at or associated with the crossing. 

(I) "Arising from the operation of a 
railroad" includes all activities of a 
railroad which are related to the per- 
formance of Its rail transportation 
business. 

(Sees. 11144 and U14S. tubtltle IV of Title 
49 (40 U.S.C. 11144 and 11145): tecs. 1 and 6. 

Accident ReporU Act (45 O.S.C. 431 and 
437); lee. We) and (f ). Department of Trans- 
portation Act (49 V£.C. ie55<e> and (O): 
aec. 1.49(f) and (m). rcffulatlona of the 



Office of the Secretary ef Transportauoa 
(49 Cnt 1.49(() and (m» 
IS9 PR 4S334. Dec. 11, IflTl as amended at 
40 FR a9S4«, July 14, lt7S: 47 FR MSH. 
Dec. 1«. 19«a] ^^ 

• ns.7 PabUc cunlnaUon aM BM or I*. 
porta. 

<a) Aoddent/lnctdent reports made 
by railroads tn compliance with these 
rules shall be available to the public In 
the manner prescribed by Part 7 of 
this Title. Accident/incident reports 
may be inspected at the Office of 
Safety. Federal Railroad Administra- 
tion. 2100 Second Street, SW.. Wash- 
ington. D.C. 20590. Written requests 
for a copy of a report should be ad- 
dressed to the Office of Chief Counsel. 
FRA. 400 Seventh Street. SW.. Wash- 
ington, D.C. 30590. and be aoecmipa- 
nled by the appropriate fee prescribed 
in Part 7 of this TlUe. To facUlUte ex- 
pedited handling, each request should 
be clearly marked "Request for Acci- 
dent/Incident Report". 

(b) Section 4 of the AcddenU Re- 
ports Act (36 SUt. 351, 45 U.S.C. 41) 
provides that monthly reports fUed by 
railroads under 1225.11 may not be 
admitted as evidence or tised for tny 
purpose in any action for damsta 
growing out of any matters mentioned 
tn these monthly reports. 

1 225.f Telephonic reporU of certain acci- 
denU/incMcnta.' ■ 

(a) Each railroad must report imme- 
diately by toll free telephone. Area 
Code 800-424-0201, whenever it learns 
of the occurrence of an accident/inci- 
dent arising from the operation of the 
railroad that resulU in the: (1) Death 
of rail passenger or employee; or (2) 
death or injury of five or more per- 
sons. 

(b) Each report must sUte the: 
(1) Name of the railroad: 



•The NaUonal TraniportaUon Safety 
Board requires certain railroad acddenU to 
be reported by telephone at the same tot 
free number (See Title 49, (»de of PMeral 
Regulationt Part S40). 

•PRA U>coffloUve Inspection Retulattom 
require certain locomotive acddenU to be 
reported by telephone at the nme toU free 
number (Sec TlOe 49. Code of Federal Rer 
ulationa. 11330.55. 330.10Z 330.335 and 
230.454). 



97 



APPENDIX H 



ft) Name, title, and telephone 
number of the indivldukl maUnc the 

'"STxime. date, and location of aod- 
dent/lnclden^ ^.^^^., 

(4) circumstanoea of the aedoent/ 
lnddent:and 

(8) Number of pertons UUed or in- 
jured. 

m FR <»»<. Dee- 11- 1"** •■ M«»«>d^ »» 
41 FR 1»W. Apr. 16. 19761 

mm Rcportlnf of accideiitt/incidenta. 

(a) Each railroad subject to this part 
must submit to FRA a monthly report 
of all railroad accidents/Incidents de- 
scribed In I 225.19. The report must be 
made on the forms prescribed in 
1 325.21 and must be submitted within 
30 days after expiration of the month 
durlnc which the aeddento/lnddenta 
occurred. Reports must be completed 
H required by the current FRA Guide 
for Preparing Accident/Incident Re- 
ports. A copy of this BuJde may be ob- 
tained from the Office of Safety. Fed- 
eral Railroad Administration. 2100 
Second Street, SW., Washlitgton. D.C. 
20SM. 

(b) As part of each monthly report, 
each Class I railroad and switching 
and terminal company must include a 
copy of its "Monthly Report of Em- 
ployees, Service and Compensation" 
(ICC Wage Statistics. Forms A and B) 
submitted to the Interstate Commerce 
Commission for the same month. 

(c) As part of its monthly reports for 
March, June, September and Decem- 
ber of each year, each Class I railroad 
and switching and terminal company 
must include copies of the current 
quarterly Form 08-A report required 
by the Interstate Commerce Commis- 
sion. As part of Its monthly reports for 
April, July. Octolter, and January of 
each year, each Class I railroad and 
switching and terminal company must 
Include copies of current quarterly 
Form 08-B report required by the 
Interstate Commerce Commission. 

CU m 1231, Jul 6. 1977) 

• m.lS UtcrayoitB. 

Whenever a i>llroad discovers that a 
report of an accident/incident, 
throu gh mistake or otherwise, has 
been Improperly omitted from or im- 



properly reported on Iti regular 
monthly aoddent/inddent report, a 
report covering this aoddent/ineident 
together with a tetter of explanaUon 
must be submitted immediately. 

ins.li AeddcBts/liiddcnts Bot to kc re- 
ported. 

A railroad need not report: 

(a) Casualties which occur at ivll- 
highway grade croeslngs that do not 
Involve the presence or operation of 
on-track equipment, or the presence of 
railroad employees then engaged in 
the operation of a railroad: 

(b) Casualties in or about living 
quarters not arising from the oper- 
ation of a railroad: 

(c) Suicides as determined by a coro- 
ner or other public authorltr. or 

(d) Attempted sulddes. 



98 
APPENDIX I 
BENCH TEST RESULTS OF PRESSURE RELIEF VALVES 

BREAKING VALUE RANGE 

Safety Valve Hold Down Bolts 

in Inch-Pounds 



ADMX 29477 








BoU 


A-end 


Bolt 


B-end 


1 


2000-2500 


1 


2500 


2 


2000-2500 


2 


Loose, hand turn 


3 


2000-2500 


3 


<2500 


4 


1500-2000 


4 


<1500 


5 


1500-2000 


5 


1500 


6 


2000-2500 


6 


1000-1500 


7 


2000-2500 


7 


1500 


8 


2000-2500 


8 


1000-1500 


ADMX 29494 








Bolt 


A-end 


Bolt 


B-end 


1 


1000-1500 


1 


1000-1500 


2 


<1000 


2 


2500 


3 


1000-1500 


3 


Loose, <1000 


4 


<1000 


4 


1500-2000 


5 


1500-2000 


5 


2500-3000 


6 


<1000 


6 


1000-1500 


7 


<1000 


7 


1000-1500 


8 


<1000 


8 


Loose, <1000 



The torque wrench used, SN REX - CIO, is normally used to 
secure roller bearing end cap screws and was calibrated against a 
mounted torque wrench gage for that purpose in the RESCAR 
Longview Shop. 



SAFETY VALVE BENCH TEST RESULTS 
in Pounds per Square Inch 

Note: These safety valves were designed to be fully open at 75 
psi and completely closed at 60 psi. 



A-end 



B-end 



ADMX 29477 
open 73 
seated 30 



open 
seated 



65 
54 



ADMX 29494 
A-end open 64 
seated 59 



B-end open 
seated 



72 
65 



"U.S.COI/ERNBIENT PRINTING OFF ICE :1989- 2^2-323 1OOOI 1 



^,^sn 



DATE DUE 
























HE 1780 .U58 89/04 
Head-on collision between 
Iowa interstate Railroad 
■ Extra 470 West and Extra 




HE 1780 .U58 89/04 
Head-on collision between 
Iowa Interstate Railroad 
Extra 470 West and Extra 



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